Metabolic syndrome treatment

ABSTRACT

Formulations and methods of providing an orally-active anti-metabolic disease Fixed Dose Combinations (FDC) for use as personalized medicine to treat different components of the Metabolic Syndrome or Insulin resistance syndrome such as Type II diabetes, Hypertension, Hyperlipidemia and Obesity are disclosed. Pharmaceutical compositions of anti-inflammatory centric drug formulations and methods comprising of NSAIDS in general and selective Cox-2 inhibitors in particular and one or more anti-T2DM or anti-hypertensive or anti-hyperlipidemic or anti-obesity drugs formulated to exhibit pre-determined modified release kinetics to achieve therapeutic as well as kinetic synergies are disclosed.

This application is a continuation-in-part of U.S. application Ser. No.14/848,972, filed Sep. 9, 2015, which claims the benefit of U.S.Provisional Application Ser. No. 62/047,766, filed Sep. 9, 2014.

FIELD OF INVENTION

The invention relates to development of drugs to treat metabolicsyndrome targeting components of the complex pathophysiology.

BACKGROUND OF THE INVENTION

Metabolic diseases in general and Type II diabetes [(T2DM or T2D or TypeII Diabetes or Non-insulin dependent mellitus (NIDDM)] in particular area complex, multigene and multifactorial disease. Metabolic diseases suchas hyperlipidemia, obesity and hypertension as well as environmentalfactors contribute to this disease. Cardiometabolic risk factor clusters(CMRFC) such as diabetes, hyperlipidemia, hypertension andoverweight/obesity often cluster together in the same individual(Garber, A. J. et al. 2013). The prevalence of these risk factors isincreasing significantly for all sociodemographic groups and it isputting an enormous economic burden on the society. Currently overone-fourth (over 70 million) of the U.S. population live withcardiovascular (CV) disease along with cardiometabolic risk factors. Theeconomic impact of CV disease is enormous. In 2005, it was estimated tobe over $242B in direct medical expenses and over $152B in indirectmedical costs including lost productivity, resulting in a totalestimated cost of $395B in the U.S. alone (Sullivan, P. W. et al. 2007).CV disease is the leading cause of death resulting in an estimated 40%(>840,000) of all the deaths. Over 225 million people worldwide and over26 million people in the USA alone suffer from Type II diabetes. In2013, the annual cost of clinical management of this disease was over$245B ($176B for direct medical costs and $69B in reduced productivity)(Statistics about diabetes, ADA, 2014). Type II diabetes was the seventhleading cause of death in the U.S. in 2010 (Mortality data, 2010, CDC).According to GB Research (Global Business Intelligence), the global TypeII diabetes market will grow from $20.4B in 2012 to $38.8B in 2019. TheU.S. market will more than double, from $12.7B in 2012 to $27.2B in 2019(GBI Research, 2013). The world market for metabolic syndrome isestimated to be $72.4B by 2018 (biovision.com).

Insulin resistance is a pathological hallmark of metabolic syndrome ingeneral and Type II diabetes in particular. Type II diabetes continuesto be an unmet medical need due to a number of factors including: theidiopathic nature of the disease, complex pathophysiology attributed toauto-immune and pro-inflammatory components, and comorbidities such ashyperlipidemia, obesity and high blood pressure (Erik, P. et al. 2009).Complexity of the disease contributes to manifestation of T2DM inmultiple and diverse pathophysiological conditions such a way that thedisease constitutes a unique pathophysiological phenomenon in eachpatient. Complexity of the disease in combination with unique metabolicprofile and life style of each patient or group of patients contributeto lack of adequate efficacy with currently marketed Type II diabetesdrugs (American College of Physicians, 2012). Moreover, Type II diabetespatients who are on current treatment regimens, continue to bevulnerable for complications such as diabetic retinopathy, skin ulcers,risk of coronary heart disease (CHD), stroke, chronic kidney disease(CKD), diabetic peripheral neuropathy, diabetic vasculopathy etc.

Type II diabetes continues to be an unmet medical need and at thecurrent rate, it will double to over 640 million T2D patients world-wideby 2030 (American Diabetes Association). It is characterized byprogressive deterioration of pancreatic beta cell dysfunction andinsulin resistance. In spite of intense treatment with mono- andcombination therapies with the existing modalities, patients suffer fromprogressive deterioration of metabolic control of glucose homeostasis(Standards of Medical Care in Diabetes, 2015). Lack of adequate glycemiccontrol as indicated by inability to reach the target glycemic (A1c),blood pressure and cholesterol levels with currently marketed standardsof medical care for Type II diabetes puts patients on a certain path todevelop diabetes-related complications such as stroke, retinopathy,neuropathy, nephropathy, and skin ulcers. With the guidelinesrecommended by the American Association of Clinical Endocrinologists,39-49% of patients do not meet targets for glycemic, blood pressure orcholesterol levels (Standards of Medical Care in Diabetes, 2015). It isneedless to say that there's a desperate need for new modalities andinnovation in the Type II diabetes space.

The complex etiology involves a combination of a variety ofinflammation-triggered cellular dysfunctions that contributeindividually and collectively to pancreatic cell dysfunction (Tateya, S.et al. 2013). Cyclooxygenase 2 or Cox-2 or COX-II is the predominantmediator of pro-inflammatory PGE2 synthesis in pancreatic islet cells(Robertson, R. P. 1998). ARKAY is advancing an innovativeanti-inflammatory pancreatic beta cell-centric platform that treatsislet cell dysfunction in combination with insulin resistance. It iswell established that signaling pathways associated with immunedysregulation, chronic low-grade inflammation associated withobesity-triggered insulin resistance, and cardiovascular disease areintricately intertwined and they are literally inseparable from eachother (Shu, C. J. et al. 2012).

Type II diabetes is characterized by impaired first phase of insulinsecretion due to progressive deterioration of pancreatic beta cellfunction which compromises its inherent capacity to compensate forinsulin resistance. Functional response of beta cells and insulinsensitivity of insulin-responsive tissues such as liver and skeletalmuscle are tightly regulated by a feed-back loop. The magnitude of betacell response is directly proportional to the tissue sensitivity ofinsulin-responsive tissues. This feedback loop determines the normalregulation of glucose metabolism and maintenance of glucose homeostasis.Beta cells have an inherent capacity to compensate with an increasedoutput of insulin when insulin resistance is present. Blood glucoselevels rise in the presence of insulin resistance when beta cells areincapable of releasing sufficient insulin due to progressivedeterioration of beta cell function.

Activation of inducible Cyclooxygenase, Cox-2 or activation ofconstitutive Cox-2 plays a critically important role in the initiationof obesity-triggered inflammation. A link between elevation of bloodglucose levels and activation of Cox-2 in pancreatic beta cells is wellestablished. High glucose-induced PGE2 causes reduction in the beta cellmass by inhibiting its proliferation as well as induction of apoptosisof beta cells (Oshima, H. et al 2006). Indomethacin, a non-selectiveCyclooxygenase inhibitor prevented HFD—(high fat diet)-induced obesityand insulin resistance in C57BL/6J mice (Fjaere E. et al. 2014).Treatment with NSAIDs (Non-steroidal anti-inflammatory drugs) such asCelecoxib and Salsalate have been shown to restore systemic insulinsensitivity in both translational preclinical models as well as in obesepatients with T2DM (Goldfine, A. B. et al. 2013; Gonzalez-Ortiz, et al.2005). High blood glucose activates Cox-2 in pancreatic beta cells andcontributes to beta cell dysfunction. Treatment with NS-398 (a selectiveCox-2 inhibitor) reverses beta cell dysfunction (Tian, V. F. et al.2014) presumably by reducing PGE2-mediated beta cell apoptosis.Obesity-triggered inflammation due high blood sugar levels results innon-alcoholic hepatic steatosis which is a pathological hallmark ofinsulin resistance. Non-alcoholic steatohepatitis (NASH) is a conditionthat coexists with T2DM. Celecoxib reverses steatohepatitis as well asinflammation in HFD-induced Wistar rat NASH model (Chen, J. et al.2011). Over-expression of NAG-1/GDF-15 (NSAIDs-activated gene-1) hasbeen shown to improve glycemic parameters and prevent development ofobesity by increasing thermogenesis, lipolysis and oxidative metabolismin obese C57BL/6J mice (Chrysovergis, K. et al. 2014). Activation ofinducible form of Cox-2 plays a critically important role in theinitiation of cellular dysfunctions including: adipocyte dysfunction,pancreatic beta islet cell dysfunction and macrophage dysfunction.Cellular dysfunctions contribute to development of insulin resistanceand systemic glucose intolerance. Cox-2 deletion in C57BL/6J obese micereduces blood glucose levels (Fujta et al. 2007). More importantly, inthe same translational preclinical model, selective Cox-2 inhibitor,Celecoxib reduces HbA1c levels, improved glucose tolerance and elevatedinsulin levels (Fujita, H. et al. 2007). Selective Cox-2 inhibitors suchas Celecoxib and Mesulid restore insulin sensitivity, reduce oxidativestress and reverse low-grade inflammation in male Sprague Dawley ratsfed with High fructose diet or High fat diet (HFD) (Hsieh, P. et al.2009; Liu, T. et al. 2009). They both reduced time-dependent increasesin plasma insulin, 8-isoprostanes, leptin levels, and reversed increasein hepatic triglycerides. Celecoxib also restored insulin sensitivity ina small study of 12 obese patients (Gonzalez-Ortiz, et al. 2005).

Renin-Angiotensin system (RAS) exists in pancreatic beta cells andAngiotensin II is pro-inflammatory in pancreas and activatespro-inflammatory cytokine IL-1 beta. Ang II-mediated Islet cellinflammation triggers beta cell dysfunction contributing to Pancreaticbeta cell exhaustion and decompensation (Sauter, N. et al. 2015). Thisoccurs independent of vasoconstriction because sub-hypertensive dose ofValsartan (1 mg/Kg/day) improves impaired glucose tolerance with noeffect on the systolic blood pressure in C57BL/6J obese mice. Blockadeof Ang II with an ARB (Angiotensin receptor blocker) such as Valsartanimproves glucose tolerance (Cole, B. K. et al. 2010) as well as restoresnot only beta cell dysfunction but also enhances blood flow as a resultof vasodilation. The anti-hypertensive drug Metformin, which isconsidered the gold standard for the treatment of T2DM ameliorates notonly HFD-induced insulin resistance but also improves glucose tolerancein C57BL/6J diet-induced obesity (DIO) model (Matsui, Y. et al. 2010;Woo, S. et al. 2014).

A number of publications have supported the importance of adipocytes andinflammation for the development of insulin resistance. For example,JNK-1 deficiency in adipocytes suppressed HFD—(High fat diet)-inducedinsulin resistance in the liver due to suppression of JNK-dependentsuppression of IL-6 (Sabio, C. et al. 2008), adipocyte-specific deletionof Glut4 or over expression of MCP-1 results in systemic insulinresistance (Qi, L. et al. 2009), TNF-alpha deficiency improved insulinsensitivity in diet-induced obesity and in Lep ob/ob model of obesityand neutralization of TNF-alpha in obese fa/fa rats ameliorated insulinresistance (Hotamisiligil, G. S. et al. 1995). Elevated IL-1 beta, IL-6and CRP are predictive of development of T2DM (Visser, M. et al. 1999)and TLR4 knock-out mice were protected from inflammation and insulinresistance (Shi, H. et al. 2006). Therefore, the lack of adequateefficacy and lack of adequate overall clinical benefit from currentlymarketed anti-hyperglycemic drugs is due to their inability to suppressthe pro-inflammatory components of the complex pathophysiology ofinitiation and maintenance of systemic insulin resistance. TZDs andstatins do have an inherent yet very modest anti-inflammatory capacitywhich contributes to their therapeutic efficacy. Therefore, suppressionof obesity-triggered chronic low-grade inflammation with ananti-inflammatory drug such as Cox-2 selective inhibitor is anticipatedto treat the impaired glucose homeostasis in T2DM patients by enhancingthe efficacy of anti-hyperglycemic drugs with an additive or synergisticeffect. Inhibition of inflammation is also anticipated to reduce theseverity of diabetes-related complications.

Inflammation is a critical component of the pathophysiology of not onlyType II diabetes but also the clinically relevant comorbidities asillustrated in FIG. 2. More importantly, pro-inflammatory signalscontribute to initiation and maintenance of complications associatedwith Type II diabetes such as diabetic retinopathy, skin ulcers, risk ofcoronary heart disease (CHD), stroke, chronic kidney disease (CKD),diabetic peripheral neuropathy, diabetic vasculopathy etc.Pro-inflammatory signals determine the severity and duration ofdiabetes-related complications. An anti-inflammatory drug, Salsalate hasbeen shown to reduce glycosylated hemoglobin A1c by an average of 0.37%in a clinical study conducted by Harvard Medical School (Goldfine, A. etal. 2013). There is a direct correlation between elevation in thepro-inflammatory biomarkers and impaired glucose metabolism. Statins andThiazolidinediones (TZDs) reduce the risk of developing diabetes byconsistently lowering the inflammatory markers (Deans K. A. and Sattar,N. (2006). Therefore, for efficient clinical management, it is importantto treat cardiometabolic diseases including Type II diabetes not as anindividual disease but as a metabolic syndrome with a complexpathophysiology with a strong pro-inflammatory component. For example,to achieve sufficient therapeutic efficacy in Type II diabetes patientswho present wide-ranging challenges and metabolic profiles, it is indeednecessary to treat with a pro-inflammatory-centric combination of drugsthat correct not only the impaired glucose homeostasis but alsoattenuate clinically relevant comorbidities and more importantly reducethe severity of diabetes-related complications. Instead of treatingpatients with metabolic syndrome as one homogeneous population with justone drug, it is necessary to treat patients with an anti-inflammatorydrug in combination with anti-metabolic disease drugs with knownefficacy and safety profile.

Patients stratified into groups for lack of adequate clinicallyfavorable response to currently marketed drugs to treat metabolicdiseases will be selected to test different Fixed Dose Combinations(FDC) formulations. Combination of drugs custom-formulated to providetherapeutic benefit to a specific stratified group of patients isanticipated to have therapeutic as well as kinetic synergy. Moreimportantly these drugs would block the pro-inflammatory components ofsome of the comorbidities as well as attenuate the severity ofcomplications such as Chronic kidney disease, diabetic neuropathy,diabetic nephelopathy, skin ulcers etc. Inclusion of ananti-inflammatory drug in every potential FDC formulation would resultin enhancing therapeutic efficacy of Type II diabetes drugs by reducingtherapeutic dose range such as minimal effective dose (MED), maximaltolerated dose (MTD) as well as the maintenance dose. Therefore,blockade of the pro-inflammatory components would contribute to sparingor reducing the severity or duration of some of the adverse sideeffects. Pro-inflammatory-centric anti-metabolic syndrome FDCformulations would result in the development of drugs that differentiateclinically as well as mechanistically from the currently availabledrugs.

The prevalence of prediabetes is 3 times more than that of Type IIdiabetes. American Diabetes Association reported that in 2012, therewere 86 million Americans 20 or older had prediabetes (Statistics aboutdiabetes, ADA, 2014). Insulin resistance as a result of failingpancreatic compensation due to excessive body weight or obesity,impaired glucose tolerance, impaired fasting glucose and symptomaticmetabolic syndrome are the pathological hallmarks of prediabetes(American College of Physicians, 2012). Currently, there are no drugsthat prevent or delay progression of prediabetes into insulin resistanceor metabolic syndrome or incidence or new-onset T2DM.

Renin-Angiotensin System (RAS) exists in the pancreatic islets (Leung,P. S. 2012; Andraws, R. and D. L. Brown, 2007). Blockade of the RASparticularly with Angiotensin II receptor blockers (ARBs) and ACE(Angiotensin-converting enzyme) inhibitors has been shown to prevent theincidence or onset of Type II diabetes in patients with impaired glucosetolerance (IGT) (Van der Zijl, N. R. et al. 2011). Moreover, innormotensive patients with impaired glucose tolerance, ARBs increaseglucose-dependent insulin secretion and enhance insulin sensitivity(McMurray, et al. 2010). Anti-inflammatory FDC formulations that combineanti-type II diabetes drugs with ARBs and ACE inhibitors will havetremendous therapeutic potential in terms of reducing the number ofprediabetes patients who are on a certain path to positive clinicaldiagnosis for Type II diabetes.

It is hypothesized that in normotensive prediabetes and Type IIdiabetes, Anti-inflammatory FDC formulations that includessub-therapeutic doses of ARBs and ACE inhibitors would enhancetherapeutic efficacy of Type II diabetes drugs by reducing therapeuticdose range [minimal effective dose (MED), maximal tolerated dose (MTD)and the maintenance dose]. Therefore, blockade of the pro-inflammatoryand RAS components would contribute to sparing or reducing the severityor duration of some of the adverse side effects associated with Type IIdiabetes drugs.

There is a continuing need for compounds, compositions, formulations andmethods to treat metabolic syndrome.

OBJECTS AND SUMMARY OF THE INVENTION

It is an object of the invention to provide methods, compositions andformulations to treat Metabolic Syndrome or Insulin resistance syndrome.

It is a further object of the invention to provide broad-spectrumpersonalized drugs to treat metabolic syndrome including metabolicdiseases such as Type II diabetes, hypertension, hyperlipidemia andobesity.

It is a further object of the invention to provide methods of treatmentof not just the primary disease but also the comorbidities, risk factorsand diabetes-related complications.

It is a further object of the invention to provide methods to treatprediabetes by preventing or delaying the new incidence or onset of TypeII diabetes.

It is an object of the invention to provide an innovative method,composition and formulation to treat prediabetes and Type II diabetes inparticular, and insulin resistance syndrome or metabolic syndrome ingeneral.

It is an object of the invention to provide an innovative method oftargeting multiple distinct yet overlapping mechanisms along the immunedysregulation-inflammation-insulin resistance axis to fill a gap thatexists in the modalities that are used in the mono- and combinationtherapies that are used for the clinical management of Type II diabetes.

It is a further object of the invention to provide proof-of-concept(POC) of the anti-inflammatory pancreatic beta cell-centric approach formanaging blood glucose (blood glucose) levels.

It is a further object of the invention to provide proof-of-concept ofthe anti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) and fasting blood glucose levels.

In accordance with the above objects and others, the present inventionrelates to the methods for treating patients with metabolic syndromewith personalized medicines. More particularly, the invention isdirected in part to filling the gap that currently exists in themodalities used for the treatment of Type II diabetes by targetingmultiple distinct yet overlapping mechanisms that contribute topancreatic beta dysfunction along the immunedysregulation-inflammation-insulin resistance axis.

The invention is directed in part to a method of providing anorally-active anti-metabolic disease Fixed Dose Combinations (FDC) foruse as personalized medicine to treat different components of theMetabolic Syndrome or Insulin resistance syndrome such as Type IIdiabetes, Hypertension, Hyperlipidemia and Obesity.

This Invention has the unique feature of personalized medicine with acustom formulation strategy to combine anti-metabolic andanti-cardiovascular disease drugs with anti-inflammatory drugs to reducethe pill burden and to achieve therapeutic as well as kinetic synergiesresulting in better efficacy, safety and compliance. Formulationstrategy described herein is aimed at providing patients and physiciansbetter choice of drugs.

The invention is further directed to formulations and methods fortreating metabolic syndrome, and in particular preventing or delayingthe onset of Type II diabetes via an innovative anti-inflammatorypancreatic beta cell-centric platform that treats islet cell dysfunctionin combination with insulin resistance. The invention is furtherdirected in part to the inclusion of an orally-active anti-inflammatorydrug as part of the composition of the drug FDC. Treating the underlyinginflammatory component of the complex pathophysiology of Type IIdiabetes with an anti-inflammatory-centric therapy represents a newshift in the paradigm of clinically managing T2DM efficiently.

The invention is further directed in part to the inclusion of anorally-active anti-inflammatory drug, at least one anti-diabetic drugand blockers of Renin-Angiotensin System (RAS) as part of thecomposition of the FDC to prevent the incidence or delay the onset ofType II diabetes.

The invention is also directed in part to formulations and methods inwhich one or more orally-active anti-inflammatory drugs will be combinedwith the orally-active anti-metabolic disease drugs in FDC ratios toachieve therapeutic as well as the kinetic synergy.

In certain embodiments, the invention is further directed in part to theuse of more than one and as many as five (or more) orally-activeanti-metabolic and anti-inflammatory FDC.

Certain embodiments of the invention are directed to the delivery of FDCof orally-active anti-inflammatory drugs and anti-metabolic diseasedrugs as a multi-layer matrix of immediate release (IR) and extendedrelease (ER) formulations. In certain embodiments of the invention, thedelivery of FDC of orally-active anti-inflammatory drugs andanti-metabolic disease drugs is accomplished via a delayed release (DR)formulation. In certain preferred embodiments of the invention, thepharmaceutical formulations of the invention utilize a combination ofimmediate release, extended release and/or delayed release for theorally-active anti-inflammatory drugs and anti-metabolic disease drugsincluded in the FDC formulation.

Further embodiments of the invention are directed in part to thedelivery of FDC of orally-active anti-inflammatory drugs andanti-metabolic disease drugs as a multi-layer matrix of IR and DRformulations along with one or more drug administered parentarally(intravenous, subcutaneous, intramuscular or intramedullary injection).

Further embodiments of the invention are directed in part to thedelivery of FDC of orally-active anti-inflammatory drugs andanti-metabolic disease drugs as a multi-layer matrix of IR and DRformulations along with one or more drug administered transdermally ornasally.

In certain embodiments, the invention is directed in part to thetreatment with an anti-inflammatory-centric FDC to treat Type IIdiabetes component of metabolic syndrome or insulin-resistant syndrometo patients in need of said therapy.

The invention is further directed in part to treatment with ananti-inflammatory-centric FDC to treat hypertension or high bloodpressure component of metabolic syndrome or insulin-resistant syndrome.

The invention is further directed in part to treatment with ananti-inflammatory-centric FDC to treat hyperlipidemia component ofmetabolic syndrome or insulin-resistant syndrome.

The invention is further directed to treatment with ananti-inflammatory-centric FDC to treat excessive bodyweight or obesitycomponent of metabolic syndrome or insulin-resistant syndrome.

The invention is further directed in part to a pharmaceuticalformulation of FDC of drugs to treat metabolic syndrome orinsulin-resistant syndrome in the form of multi-layered monolithictablets.

The invention is further directed in part to a pharmaceuticalformulation of FDC of drugs to treat metabolic syndromeinsulin-resistant syndrome in the form of core tablet-in-tablet ormulti-disc tablets.

The invention is further directed in part to a pharmaceuticalformulation of FDC of drugs to treat metabolic syndromeinsulin-resistant syndrome in the form of beads inside a capsule.

The invention is further directed in part to the use of more than oneand as many as five (or more) orally-active drug FDC of IR, IR and DR,and IR and ER formulations for preventing or slowing down prediabetes inthe form of multi-layered monolithic tablet or coretablet-in-tablet/multi-disc tablets or beads inside a capsule or tabletsinside a capsule.

In certain preferred embodiments, the present invention is directed inpart to pharmaceutical formulation for the treatment of metabolicsyndrome comprising a therapeutically effective amount(s) of an activeagent selected from the group consisting of at least one anti-diabeticdrug; or a therapeutically effective amount of at least oneanti-hypertensive drug; or a therapeutically effective amount of atleast one anti-obesity drug; or a therapeutically effective amount of atleast one drug for the treatment of hyperlipidemia; or a combination ofany of the foregoing; and a therapeutically effective amount of at leastone orally active anti-inflammatory drug. In certain preferredembodiments, the pharmaceutical formulation comprises a therapeuticallyeffective amount(s) of a drug selected from the group consisting of atleast one anti-diabetic drug, an anti-hypertensive drug, and atherapeutically effective amount of at least one orally activeanti-inflammatory drug.

In certain preferred embodiments, the pharmaceutical formulation of theinvention comprises therapeutically effective amounts of at least twodrugs selected from the group consisting of at least one ananti-hypertensive drug, at least one anti-diabetic drug, at least onedrug for the treatment of hyperlipidemia, at least one anti-obesitydrug, and at least one anti-inflammatory drug. In certain embodiments,the pharmaceutical formulation of the invention comprisestherapeutically effective amounts of a drug in at least three, at leastfour or at least five of the afore-mentioned drug classes. In certainpreferred embodiments, the pharmaceutical formulation of the inventioncomprises therapeutically effective amounts of at least one ananti-hypertensive drug, at least one anti-diabetic drug, at least oneanti-obesity drug, and at least one anti-inflammatory drug. In certainpreferred embodiments, the pharmaceutical formulation of the inventioncomprises therapeutically effective amounts of at least one ananti-hypertensive drug, at least one anti-diabetic drug, at least onedrug for the treatment of hyperlipidemia, at least one anti-obesitydrug, and at least one anti-inflammatory drug.

In certain preferred embodiments, the pharmaceutical formulation of theinvention includes an anti-hypertensive drug that is a blocker ofRenin-Angiotensin System (RAS).

In certain preferred embodiments in which the metabolic syndrome is TypeII diabetes, the pharmaceutical formulation comprises therapeuticallyeffective amounts of a combination of one or more anti-inflammatorydrug(s) and at least one drug used in the treatment of Type II Diabetes.In certain of such embodiments, the pharmaceutical formulation furthercomprises a drug that is a blocker of Renin-Angiotensin System (RAS).

In certain preferred embodiments in which the metabolic syndrome ishyperlipidemia, the pharmaceutical formulation of the inventioncomprises therapeutically effective amounts of a combination of one ormore anti-inflammatory drug(s) and one or more drugs selected from thegroup consisting of a statin, niacin, a fibrate, and combinations of anyof the foregoing.

In certain preferred embodiments in which the metabolic syndromeinvolves obesity, the pharmaceutical formulation of the inventioncomprises therapeutically effective amounts of a combination of one ormore anti-inflammatory drug(s) and one or more drugs selected from thegroup consisting of an anti-obesity drug, an anti-diabetic drug, andcombinations of any of the foregoing. In certain preferred embodiments,the pharmaceutical formulation for the treatment of obesity furthercomprises a drug for the treatment of hyperlipidemia and/orhypertension.

In certain preferred embodiments in which the metabolic syndromeinvolves hypertension, the pharmaceutical formulation of claim 1comprises therapeutically effective amounts of one or more drugsselected from the group consisting of a beta blocker, a diuretic, an ACEinhibitor, an Angiotension II Type 1 Receptor Blocker (ARBs), Calciumchannel blocker (CCBs), a central agonist, a peripheral-actingadrenergic blocker, a direct vasodilator, a direct renin inhibitor, andcombinations of any of the foregoing; and at least one anti-inflammatorydrug. In certain preferred embodiments, the pharmaceutical formulationof the invention for the treatment of metabolic syndrome that involveshypertension further comprises therapeutically effective amounts of oneor more drugs selected from the group consisting of an anti-obesitydrug, an anti-diabetic drug, a drug for the treatment of hyperlipidemia,and combinations of any of the foregoing.

The pharmaceutical formulation may be any that is known to those skilledin the art and useful to administer the drugs in the FDC. In certainpreferred embodiments, the pharmaceutical formulation is an oral soliddosage form. In other preferred embodiments, the pharmaceuticalformulation is an injectable formulation which is administeredparenterally (intravenous, subcutaneous, intramuscular, orintramedullary injection). In yet other embodiments of the invention,the pharmaceutical formulation is administered transdermally or nasally.The pharmaceutically formulation of claim 1, which is in liquid form.

In certain preferred embodiments which include an antidiabetic drug(s),the anti-inflammatory drug and the antidiabetic drug(s) are in immediaterelease form. In other preferred embodiments, at least one of the drugsis in controlled or delayed release form.

The invention is further directed in part to a method of treatingmetabolic syndrome, comprising administering to a human patient having acondition selected from the group consisting of Type II diabetes,Hypertension, Hyperlipidemia and Obesity, a pharmaceutical formulationfor the treatment of metabolic syndrome comprising a therapeuticallyeffective amount(s) of a drug selected from the group consisting of atleast one anti-diabetic drug; or a therapeutically effective amount ofat least one anti-hypertensive drug; or a therapeutically effectiveamount of at least one anti-obesity drug; or a therapeutically effectiveamount of at least one drug for the treatment of hyperlipidemia; or acombination of any of foregoing; and a therapeutically effective amountof at least one orally active anti-inflammatory drug. In certainembodiments wherein the patient is diabetic or prediabetic, the methodfurther comprises administering a therapeutically effective amount(s) ofa drug selected from the group consisting of at least one anti-diabeticdrug, a blocker of Renin-Angiotensin System (RAS), and a combination ofthe foregoing, together with a therapeutically effective amount of atleast one orally active anti-inflammatory drug. In further preferredembodiments wherein the metabolic disease involves hypertension, themethod further comprises the administration of one or more of an ACEinhibitor, an angiotension II receptor Type 1 blocker (ARBs), a DPPIVinhibitor, at least one anti-diabetic drug, a blocker ofRenin-Angiotensin System (RAS), together with a therapeuticallyeffective amount of at least one orally active anti-inflammatory drug,to the patient.

It is comtemplated that all of the methods of the present inventionencompass the chronic treatment of the metabolic condition(s). Thus, inpreferred embodiments, the drugs (e.g., antidiabetic, antihypertensive,anti-obesity, drug for hyperlipidemia; together with ananti-inflammatory drug) are administered to the patient on a chronicbasis. In certain preferred embodiments, these drugs are administered aspersonalized medicines to clinically manage Type II diabetes orprediabetes in stratified groups of human patients based on theircardiometabolic risk factor profiles. In further preferred embodiments,the drugs are administered as personalized medicines to clinicallymanage Type II diabetes or prediabetes groups of patients stratified forlack of adequate therapeutic efficacy with prior treatments.

In embodiments in which the metabolic syndrome involves Type IIdiabetes, in certain embodiments the method further comprisesconcomitantly administering insulin to the patient to achieve betterblood glucose control. In certain of such preferred embodiments, dosageis adjusted on the basis of glucose measurements.

The invention is further directed in part to the use of more than oneand as many as five orally-active drug FDC of IR, IR and DR and IR andER formulations for other therapeutic areas.

This invention relates to the pro-inflammatory component of the complexpathophysiology (FIG. 3) as well as the cardiometabolic risk factorclusters (CMRFC) and/or comorbidities of the metabolic syndrome.

This invention relates in part to the Renin-Angiotensin system (RAS)that exists in the pancreatic islets.

This invention describes the overall clinical benefits of blocking thepro-inflammatory components and the RAS in combination with currentlymarketed drugs that are used to treat Type II diabetes, Hypertension,Hyperlipidemia and Obesity.

This invention describes the overall clinical benefits of blocking thepro-inflammatory components and the RAS in combination with drugs thatwill be discovered and developed in the future to treat Type IIdiabetes, Hypertension, Hyperlipidemia and Obesity.

Inflammation and RAS are critical components of the development ofinsulin resistance which is a pathological hallmark of Type II diabetesas well as the metabolic syndrome. This invention describes customizedunique formulation strategies that combine anti-metabolic disease drugswith anti-inflammatory drugs and/or blockers of RAS in the form ofImmediate release (IR) or Quick Release (QR) and Extended release(ER)/Sustained release (SR)/Controlled release (CR) and Delayed release(DR) depending on the needs of the individual patient or group ofpatients.

In certain embodiments of the invention, Fixed Dose combinations (FDC)of drugs may contain blockers or activators of therapeutic targetsrelevant for treating metabolic diseases and the inflammatory componentof the pathophysiology.

In certain embodiments of the invention, FDC formulation of drugs willbe prepared in fixed dose ratios to achieve the intended therapeuticefficacy for preventing the incidence of (prophylactic) or delay theprogression of prediabetes into insulin resistance syndrome or metabolicsyndrome.

In certain embodiments of the invention, FDC of drugs will be preparedin fixed dose ratios to achieve the intended (e.g. anti-type IIdiabetes, anti-hypertensive, lipid lowering and anti-obesity or acombination of thereof) therapeutic efficacy.

In certain embodiments of the invention, depending on thecardiometabolic risk factor profiles of stratified patients, the FDC ofdrugs will be prepared in fixed dose ratios of two drug combinations(e.g. anti-inflammatory and anti-Type II diabetic, anti-inflammatory andlipid lowering or anti-inflammatory and anti-hypertensive oranti-inflammatory and anti-obesity) or three drug combinations (e.g.Anti-inflammatory, Anti-Type II diabetic, Anti-hypertensive orAnti-inflammatory, Anti-Type II diabetic, Lipid lowering orAnti-inflammatory, Anti-Type II diabetic, Anti-obesity orAnti-inflammatory, Anti-hypertensive, Lipid lowering orAnti-inflammatory, Anti-obesity, Anti-hypertensive or Anti-inflammatory,Lipid lowering, Anti-obesity) or four drug combinations (e.g.Anti-inflammatory, Anti-Type II diabetic, Lipid lowering,Anti-hypertensive or Anti-inflammatory, Anti-Type II diabetic, Lipidlowering, Anti-obesity or five drug combinations (e.g.Anti-inflammatory, Anti-Type II diabetic, Lipid lowering,Anti-hypertensive, Anti-obesity) to achieve the intended therapeuticefficacy. In certain embodiments, the FDC of drugs will be prepared infix dose ratios of more than five drug combinations.

In certain embodiments of the invention, the FDC of drugs will beprepared in fixed dose ratios of two drug combinations of two, three,four and five drug combinations includes an anti-diabetic injectable.

In certain embodiments of the invention, drugs will be formulated withthe same drug as FDC of IR and ER.

In certain embodiments of the invention, FDC of drugs will be formulatedto contain the same drug in the form of IR and DR.

In certain embodiments of the invention, FDC of drugs will be formulatedto contain IR and DR of the same drug along with ER of a second drug.

In certain embodiments of the invention, FDC of drugs will be formulatedto contain IR and ER of the same drug along with the IR of a seconddrug.

In certain embodiments of the invention, FDC of drugs will be formulatedto contain IR of one drug, ER of a second and a third drug and IR of afourth drug.

In certain embodiments of the invention, combination of drugs will bemade as a monolithic FDC tablet composed of two or more activeformulations mixed and compressed in a single layer tablet.

In certain embodiments of the invention, FDC of drugs will be preparedeither in the form of a multi-layered monolithic tablet.

In certain embodiments of the invention, FDC of drugs will be preparedeither in the form of a multi-layered monolithic tablet inside a tablet.

In certain embodiments of the invention, FDC of drugs will be preparedeither in the form of a core tablet-in-tablet or multi-layeredmulti-disk tablet (MLMDT) consisting of a tablet core formulationsurrounded by a second outer formulation.

In certain embodiments of the invention, FDC of drugs will be preparedin the form of beads inside a capsule. Each bead would representdifferent color and coating level depending on the kinetics of drugrelease. For example, some beads would release drugs immediately (IR).Some would beads would release for an extended period of time (ER),while some after a long while (DR).

In certain embodiments of the invention, FDC of drugs will be preparedeither in the form of mini tablets inside a capsule. Uniquelycolor-coded capsules represent customized formulations that contain aunique combination of drugs with predetermined modified releasekinetics. Colors and shapes of tablets represent individual drugs(either same or different) and coating level depending on the kineticsof modified drug release. For example, white colored tablet is releasedimmediately (IR or QR), red colored tablet is released for an extendedperiod of time (ER or SR or XR) and light green tablet is released aftera long delay (DR).

In certain embodiments of the invention, FDC of drugs will be preparedin liquid formulations.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of a combination of ananti-inflammatory drug(s) and one or more drugs which are used in thetreatment of Type II Diabetes drugs. The drugs can be in immediaterelease form, or they can be in controlled (used synonymously hereinwith sustained or extended) release form. In yet other embodiments oneor more of the drugs can be in immediate release form and the other(s)in controlled or delayed release form. In certain embodiments of theinvention, the FDC formulation comprises a combination of ananti-inflammatory drug and two drugs which are used in the treatment ofType II Diabetes. For example, anti-diabetic drugs may be chosen fromone or more of a sulfonylurea, a biguanide (e.g., metformin and thelike), a DPP-IV inhibitor, an SGLT-2 inhibitor, and/or an incretinmimetic. In preferred embodiments, an anti-inflammatory drug is includedin the FDC formulation.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts a combination including one or morelipid lowering drugs. The drugs can be in immediate release form, orthey can be in controlled (used synonymously herein with sustained orextended) release form. In yet other embodiments one or more of thedrugs can be in immediate release form and the other(s) in controlledrelease form. In certain embodiments of the invention, the FDCformulation comprises a combination of at least two of ananti-inflammatory drug, a statin and niacin. In certain otherembodiments of the invention, the FDC formulation comprises acombination of at least two of an anti-inflammatory drug, a statin,niacin and a fibrate. In certain other embodiments of the invention, theFDC formulation comprises a combination of at least two of ananti-inflammatory drug, a statin, a fibrate and niacin. These drugs canbe in controlled (used synonymously herein with sustained or extended)release form one or more of the drugs can be in immediate release formand the other(s) in controlled or delayed release form. In preferredembodiments, an anti-inflammatory drug is included in the FDCformulation.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of a combination including one or moreanti-hypertensive drugs. The drugs can be in immediate release form, orthey can be in controlled (used synonymously herein with sustained orextended) or delayed release form. In yet other embodiments one or moreof the drugs can be in immediate release form and the other(s) incontrolled or delayed release form. In certain embodiments of theinvention, the FDC formulation comprises a combination of a diuretic anda beta blocker. In certain other embodiments of the invention, the FDCformulation comprises a combination of at least two of ananti-inflammatory drug, a beta blocker, a diuretic, an ACE inhibitor, anAngiotension II Receptor Blocker (ARBs), Calcium channel blocker (CCBs),a central agonist, a peripheral-acting adrenergic blocker, a directvasodilator, or a direct renin inhibitor. These drugs can be incontrolled (used synonymously herein with sustained or extended) ordelayed release form and one or more of the drugs can be in immediaterelease form and the other(s) in controlled release form. In preferredembodiments, an anti-inflammatory drug is included in the FDCformulation.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts a combination including one or moreanti-obesity drugs. The drugs can be in immediate release form, or theycan be in controlled (used synonymously herein with sustained orextended) or delayed release form. In yet other embodiments one or moreof the drugs can be in immediate release form and the other(s) incontrolled or delayed release form. In certain other embodiments of theinvention, the FDC formulation comprises a combination of at least twoof an anti-inflammatory drug, an anti-obesity drug, a DPPIV inhibitor,and an incretin mimetic. These drugs can be in controlled (usedsynonymously herein with sustained or extended) or delayed release formand one or more of the drugs can be in immediate release form and theother(s) in controlled release form. In preferred embodiments, ananti-inflammatory drug is included in the FDC formulation.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts a combination including one or moredrugs for prediabetes or the prevention of onset of Type II diabetes.The drugs can be in immediate release form, or they can be in controlled(used synonymously herein with sustained or extended) or delayed releaseform. In yet other embodiments one or more of the drugs can be inimmediate release form and the other(s) in controlled or delayed releaseform. In certain other embodiments of the invention, the FDC formulationcomprises a combination of at least two of an anti-inflammatory drug, anACE inhibitor, an angiotension II receptor blocker (ARBs), and anantidiabetic drug as previously described above. These drugs can be incontrolled (used synonymously herein with sustained or extended) ordelayed release form and one or more of the drugs can be in immediaterelease form and the other(s) in controlled release form. In certainpreferred embodiments, the FDC formulation includes an anti-diabetic inboth immediate release and delayed release form (e.g., a biguanide suchas metformin). In preferred embodiments, an anti-inflammatory drug isincluded in the FDC formulation.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts a combination including one or moredrugs for the treatment of metabolic syndrome. The drugs can be inimmediate release form, or they can be in controlled (used synonymouslyherein with sustained or extended) or delayed release form. In yet otherembodiments one or more of the drugs can be in immediate release formand the other(s) in controlled or delayed release form. In certain otherembodiments of the invention, the FDC formulation comprises acombination of at least two of (and preferably at least three of or allof the following) an anti-inflammatory drug, an ACE inhibitor, anangiotension II receptor blocker (ARBs), and a DPPIV inhibitor. Thesedrugs can be in controlled (used synonymously herein with sustained orextended) or delayed release form and one or more of the drugs can be inimmediate release form and the other(s) in controlled release form. Inpreferred embodiments, an anti-inflammatory drug is included in the FDCformulation.

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of Type II diabetes drugs such asolder shorter-acting sulfonyl ureas such as Dymelor (acetohexamide, 50mg to 500 mg), Diabenese (chloropropamide, 100 mg to 500 mg), Orininase(tolbutamide, 250 to 500 mg), Tolinase (Tolazamide, 100 to 250 mg) ornewer sulfonylureas such as Glucotrol (Glipizide, 2.5 mg to 30 mg),Glucotrol XL (2.5 mg to 100 mg), DiaBeta (glyburide, 1.25 mg to 20 mg),Micronase (1.25 mg to 20 mg), Glynase (glyburide/Glibenclamide, 0.75 mgto 12 mg), Glynase PresTab (glyburide, 0.75 mg to 12 mg), Amaryl(glimepiride, 1 mg to 8 mg) or biguanides such as Metformin (Glucophage,Glucophage XR, Riomet, Fortamet and Glumetza, 250 mg to 2550 mg) orThiozolidinediones (TZDs) such as Actos (pioglitazone, 5 mg to 30 mg)Avandia (rosiglitazone, 2 mg to 8 mg), or Alpha glucosicase inhibitorssuch as Precose (acarbose, 25 mg to 100 mg), Glyset (miglitol, 25 mg to100 mg) or Dipeptidyl peptidase inhibitors (DPPIV) such as Januvia(sitagliptin, 10 mg to 100 mg), Nesina (alogliptin, 2.5 mg to 25 mg),Onglyza (linagliptin, 2.5 mg) or incretin mimetic such as Repaglinide(Prandin, 2.5 ug to 10 ug), Nateglinide (Starlix, 2.5 ug to 10 ug),Exenatide (Byetta, Bydureon, 2.5 ug to 10 ug), Liraglutide (Victoza,0.25 mg to 1.8 mg) or Sodium Glucose co-transporters (SGLT-2) inhibitorssuch as Farxiga (dapagliflozin, 2.5 mg to 10 mg) and Invokana(canagliflozin, 50 mg to 100 mg).

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of high cholesterol/lipid loweringdrugs such as Atorvastatin (Lipitor, 5 mg to 80 mg), Fluvastatin(Lescol, 10 mg to 80 mg), Lovastatin (Mevacor, 5 mg to 80 mg),Provastatin (Pravachol, 20 mg to 80 mg), Rosuvastatin (Crestor, 2.5 mgto 40 mg), Simvastatin (Zocor, 2.5 mg to 40 mg) or Nicotinic acid suchas Nicolar (250 mg to 500 mg), Niaspan (250 mg to 2000 mg) or Bile acidresins (sequestrants) such as Questran (4.5 g to 9 g) and Questran Light(2.5 g to 24 g), Colestid (1 g to 16 g), Welchol (1 g to 3.75 g) orFibrates such as Atromid (20 mg to 145 mg), Tricor (24 mg to 145 mg),Lopid (500 mg to 1200 mg), Ezetimide (Zetia, 2.5 mg to 10 mg).

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of anti-inflammatory drugs such asCelebrex (Celecoxib, 25 mg to 200 mg), Advil, Motrin (Ibuprofen, 100 mgto 3200 mg), Aleve (Naproxen, sodium, 100 mg 1650 mg), Ascriptin (200 mgto 325 mg), Ecotrin (50 mg to 325 mg), Asprin (81 mg to 325 mg), Anaprox(Naproxen Sodium, 100 mg to 1650 mg), Clinoril (Sulindac, 100 mg to 400mg), DayProv (Oxaprozin, 500 mg to 1200 mg), Disalcid (Salsalate, 500 mgto 3 g), Dolobid (Difflumisal, 250 mg to 750 mg), Feldene (Piroxieum, 5mg to 20 mg), Indocin (Indomethacin, 25 mg to 100 mg), Lodine (Etodolac,100 mg to 500 mg), Mobic (Meloxicam, 5 mg to 20 mg), Naprosyn (Naproxen,100 mg to 1650 mg), Relafen (Nabumetone, 500 mg to 2000 mg), Toradol(Ketorolactromethamine, 10 to 40 mg), Vimovo (Naproxen/esomeprazole, 375mg/20 mg), Voltaren (Diclofenac, 50 mg 100 mg), Xeljanz (TofactinibCitrate, 2.5 mg to 5 mg), Anakinra (Anti-IL6 Ab, 50 mg to 100 mg),Humira (Anti-TNF-alpha Ab, 5 mg 10 mg).

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of anti-hypertensive drugs such asDiuretics (Aldactone (Spiranolactone, 25 mg to 400 mg), Dyrenium(Triampeterene, 50 mg to 100 mg), Esidix, Hydrodiuril & Microzide(Hydrochlorothiazide or HCTZ, 12.5 mg to 100 mg), Hygroton & Thalitone(Chlorthalidone, 10 mg to 100 mg), Lasix (Furosemide, 10 mg to 600 mg),Lozol (Amiloride hydrochloride, 1.25 mg to 5 mg), Mykrox (0.5 mg) andZaroxylyn (2.5 mg) (Metolazone) or Beta blockers (Blocadren (Timolol, 5mg to 60 mg), Cartrol (Cartelol Hydrochloride, 1.25 mg to 10 mg), Coreg(Corredilol, 3.125 mg to 50 mg), Coregard (Nadolol, 20 mg to 160 mg),Inderal (Propranolol, 20 mg 640 mg), Kerlone (Betaxolol, 5 mg to 40 mg),Levatol (Penbutolol Sulfate, 10 mg to 80 mg), Lopressor & Toprol XL(Metoprolol, 50 mg to 450 mg), Sectral (Acebutolol, 200 mg to 1200 mg),Tenormin (Atenolol, 25 mg to 200 mg), Visken (Pindolol, 2.5 mg 60 mg),Zebeta (Bisprolol fumarate, 1.25 mg to 20 mg), Normodyne and Trandate(Labetolol, 50 mg to 2400 mg) or Alpha blockers (Cardura (Doxazocin, 1mg to 16 mg), Hytrin (Terazocin, 1 mg to 20 mg), Minipress (Prazocin, 1mg to 20 mg) or Angiotensin-converting enzyme inhibitors: Accupril(Quinapril, 5 mg to 80 mg), Altace (Ramipril, 2.5 mg to 20 mg), Capoten(Captopril, 25 mg to 450 mg), Mavik (Trandolapril, 1 mg to 8 mg),Lotensin (Benazepril, 5 mg to 40 mg), Monopril (Fosinopril, 5 mg to 80mg), Prinvil & Zestril (Lisinopril, 5 mg to 80 mg), Univasc (moexipril,5 mg to 60 mg), Vasotec (Enalapril, 2.5 mg to 40 mg) or Angiotensinreceptor type 1 blockers: Atacand (Candesartan, 4 mg to 32 mg), Avapro(Irbesartan, 75 mg to 300 mg), Benicar (Olmesartan, 10 mg to 40 mg),Cozaar (Losartan, 25 mg to 100 mg), Diovan (Valsartan, 40 mg to 320 mg),Micardis (Telmisartan, 20 mg to 80 mg), Teveten (Eprosartan, 400 mg to800 mg) or Calcium channel blockers, Adalat and Procardia (Nifedipine,10 mg to 60 mg), Calan, Covera, Isoptin, Verelan, and others (Verapamil,120 mg to 300 mg), Cardene (Nicardipine, 20 mg to 60 mg), CardizemCartia, Dilacor, and Tiazac (Diltiazem, 5 mg to 420 mg), DynaCirc(Isradipine, 2.5 mg to 10 mg), Plendil (Felodipine, 2.5 mg to 10 mg),Norvasc (Amlodipine, 2.5 mg to 10 mg), Sular (Nisoldipine, 5 mg to 60mg) or Central agonists: Aldomet (Methyldopa, 250 to 500 mg), Catapres(Clonidine, 0.1 mg to 2.4 mg), Tenex (Guanfacine, 1 mg to 3 mg),Wytensin (Guanabenz, 2 mg to 32 mg) or Peripheral-acting adrenergicblockers: Hylorel (Guanadrel, 5 mg to 75 mg), Ismelin (Guanethidine, 5mg to 50 mg), Serpasil (Reserpine, 0.1 mg to 0.5 mg) or Directvasodilators: Loniten (Minoxidil, 2.5 mg to 100 mg), Apresoline(Hydralazine, 5 mg to 300 mg) or Direct renin inhibitors (Tekturana(Aliskiren, 75 mg to 300 mg).

In certain embodiments of the invention, the FDC formulation comprisestherapeutically effective amounts of Anti-Obesity drugs such as Orlistat(Xenical, 60 mg to 120 mg), Orlistat (Alli) OTC (30 mg to 60 mg),Phentermine (15 mg to 37.5 mg) Lorcaserin (Belviq, 5 mg to 10 mg),Phentermine/Topimerate (Qsymia, 3.75 mg/23 mg to 7.5 mg/46 mg).

The invention is further directed to a pharmaceutical formulationcomprising a therapeutically effective amount of a Type II diabetesdrug, an anti-inflammatory drug, and an angiotensin II type 1 receptorblocker. In certain preferred embodiments, the dose of one or more ofthe Type II diabetes drug, an anti-inflammatory drug, and an angiotensinII type 1 receptor blocker are sub-therapeutic. In certain preferredembodiments, the angiotensin II type 1 receptor blocker increasesinsulin sensitivity. In certain preferred embodiments, the Type IIdiabetes drug is a biguanide drug. In certain preferred embodiments, theangiotensin II type 1 receptor blocker is valsartan. In certainpreferred embodiments, the anti-inflammatory drug has COX-2 inhibitorproperties. In further preferred embodiments, a unit dose of theformulation comprises from about 50 mg to about 400 mg celexoxib, fromabout 250 mg to about 2000 mg metformin, and from about 40 mg to about320 mg valsartan. In certain preferred embodiments, the unit dose is afixed unit dose that is orally administered to human patients on achronic basis. In certain preferred embodiments, the dose of celexociband/or the dose of valsartan is sub-therapeutic.

In further preferred embodiments, the invention is directed in part to apharmaceutical formulation comprising a therapeutically effective amountof an anti-diabetic drug(s), a therapeutic or sub-therapeutic amount ofa pharmaceutically acceptable COX-2 inhibitor, and a therapeutic orsub-therapeutic amount of valsartan. In certain preferred embodiments,the anti-diabetic drug is metformin. In certain preferred embodiments,the COX-2 inhibitor is celecoxib. In certain preferred embodiments, thedose of metformin is sub-therapeutic. In certain preferred embodiments,the dose of celecoxib is sub-therapeutic. In certain embodiments, thedose of metformin and the dose of celecoxib are both sub-therapeutic. Insuch embodiments, the dose of metformin may be, e.g., less than about500 mg and the dose of celecoxib may be, e.g., less than about 80 mg.

The invention is further directed in part to a method of treating adiabetic or pre-diabetic condition in a mammal, comprising orallyadministering a fixed dose combination comprising a biguanide, anon-steroidal anti-inflammatory, and an Angiotensin II Type 1 receptorblocker on a chronic basis. In certain preferred embodiments, the doseof the non-steroidal anti-inflammatory drug and/or the dose of theAngiotensin II Type 1 receptor blocker is sub-therapeutic. In certainpreferred embodiments, the biguanide is metformin and the AngiotensionII Type 1 receptor 1 receptor blocker is valsartan. In certain preferredembodiments, the administration of the fixed dose combination improvesnon-fasting blood glucose levels in less than one hourpost-administration and fasting blood glucose levels in less than 15minutes after the oral glucose load in the Oral Glucose Tolerance Test(OGTT).

In certain preferred embodiments, the invention is directed in part to apharmaceutical formulation comprising a combination of ananti-inflammatory drug (e.g., celecoxib) together with a biguanide, bothin immediate release form. In other embodiments, the invention isdirected in part to a pharmaceutical formulation comprising acombination of an anti-inflammatory drug (e.g., celecoxib) together witha biguanide, wherein the anti-inflammatory drug is in immediate releaseform and the biguanide drug is in an extended release form. Yet otherembodiments of the invention are directed in part to a pharmaceuticalformulation comprising a combination of an anti-inflammatory drug (e.g.,celecoxib) together with a biguanide, wherein the anti-inflammatory drugis in immediate release form and a portion of the biguanide drug is inimmediate release form and the other portion of the biguanide drug is inan extended release form. Yet other embodiments of the invention aredirected in part to a pharmaceutical formulation comprising acombination of an anti-inflammatory drug (e.g., celecoxib) together witha biguanide, wherein the anti-inflammatory drug is in immediate releaseform and a portion of the biguanide drug is in immediate release form, aportion of the biguanide drug is in an extended release form, and theremaining portion of the biguanide drug is in delayed release form.

In certain preferred embodiments, the invention is directed in part to apharmaceutical formulation comprising a combination of ananti-inflammatory drug (e.g., celecoxib) together with an ARB (e.g.,valsartan), wherein the anti-inflammatory drug is in immediate releaseform and the ARB is in delayed release form. In certain otherembodiments, the invention is directed in part to a pharmaceuticalformulation comprising a combination of an anti-inflammatory drug (e.g.,celecoxib) together with an ARB (e.g., valsartan), wherein theanti-inflammatory drug is in immediate release form and the ARB is inextended release form.

Further preferred embodiments of the invention are directed in part to apharmaceutical formulation comprising a combination of ananti-inflammatory drug (e.g., celecoxib), a biguanide drug (e.g.,metformin), and an ARB (e.g., valsartan). In certain embodiments, theanti-inflammatory drug is in immediate release form, the biguanide is inimmediate release form, and the ARB is in delayed release form. In otherembodiments, the the anti-inflammatory drug is in immediate releaseform, the biguanide is in extended release form, and the ARB is indelayed release form. In yet other embodiments, the anti-inflammatorydrug is in immediate release form, a portion of the biguanide is inextended release and the other portion of the biguanide is in delayedrelease form, and the ARB is in delayed release form. In yet otherembodiments, the anti-inflammatory drug is in delayed release form, thebiguanide is in immediate release form, and the ARB is in immediaterelease form. In yet other embodiments, a portion of theanti-inflammatory drug is in immediate release form and the otherportion is in extended release form, the biguanide is in extendedrelease form, and the ARB is in delayed release form.

For purposes of the present invention, it is to be understood that theabove dosages of drugs are approximate and that the appended claimsencompass obvious variations of the same. It is further contemplatedthat other drugs in the same drug classes can be substituted for theabove drugs/dosages, and such obvious changes are encompassed by theappended claims.

For purposes of the present invention, the term “drug” is usedinterchangeably with the term “agent” or “active agent” or “testarticle”.

For purposes of the present invention, the term “FDC” or “fixed dosecombination” refers to a pharmaceutical formulation containing aspecific therapeutically effective dose of one or more orally-activeanti-inflammatory drugs as described in this specification and aspecific therapeutically effective dose of one or more anti-metabolicdisease drugs as described in this specification in any pharmaceuticallyacceptable carrier(s) such that the pharmaceutical formulation issuitable, e.g., for oral administration, parenteral administration,transdermal administration, nasal administration, buccal administration,topical administration. It is contemplated that the FDC may comprise oneor more dosage forms administered concurrently in order to provide thedesired therapeutic effect. It is further contemplated that the FDC mayencompass one or more routes of administration of the anti-inflammatoryand anti-metabolic disease drugs as described herein in order to obtaina desired therapeutic effect. It is contemplated that multiple FDCcombinations of the same drug combinations may be made available inorder to provide a desired therapeutic effect in different humanpatients.

For purposes of the present invention, the term “lack of adequateefficacy” is defined as inability to meet the target goals for A1c,blood pressure and cholesterol with prior treatments.

In certain preferred embodiments of the invention, the FDC formulationof the invention comprises a combination of 50 mg to 400 mg Celecoxib (aselective Cox-2 inhibitor), 250 to 2000 mg of Metformin (a biguanide)and an ARB 40 mg to 320 mg Valsartan (Angiotensin II type 1 receptorblocker, an ARB).

BRIEF DESCRIPTION OF FIGURES

FIG. 1 is comparison of white adipose tissue (WAT) from a lean animalwith that of an obese insulin resistant animal: infiltration ofmacrophages into WAT.

FIG. 2 is a schematic illustration of the Complex pathophysiology ofmetabolic syndrome.

FIG. 3 shows that deletion of Cox-2 in C57BL/6J obese mice reduces bloodglucose levels.

FIG. 4 shows that selective Cox-2 inhibitor, SC58236 reduces HbA1clevels in C57BL/6J obese mice.

FIGS. 5A and 5B show that selective Cox-2 inhibitor, SC58236 improvesglucose tolerance and elevates plasma insulin levels in C57BL/6J obesemice.

FIG. 6 shows that selective Cox-2 inhibitor, Celecoxib reversessteatohepatitis and inflammation in Wistar rat NASH model.

FIG. 7 shows that metformin improves glucose tolerance in C57BL/6Jdiet-induced obesity (DIO) mice.

FIG. 8 shows that Valsartan improves glucose tolerance in C57BL/6Jdiet-induced obesity (DIO) mice.

FIG. 9 is a graph plotting mean blood glucose (mg/dl) levels versus timeafter first dose (hrs) showing that co-administration of Metformin (300mg/Kg), Celecoxib (20 mg/Kg) and Valsartan (2 mg/Kg) administrationimproves non-fasting blood glucose levels on day 1 of theadministration, wherein the arrow indicates lowering of blood glucose asa result of an increase in first phase of insulin secretion which is ahallmark of improvement in pancreatic beta cell function.

FIG. 10 is a graph plotting mean blood glucose (mg/dl) levels versustime after first dose (days) showing that shows co-administration ofMetformin (300 mg/Kg), Celecoxib (20 mg/Kg) and Valsartan (2 mg/Kg)administration improves non-fasting blood glucose levels days 1 through5.

FIG. 11 is a graph plotting mean blood glucose (mg/dl) levels versustime after first dose (hrs) showing that co-administration of Metformin(150 mg/Kg), Celecoxib (10 or 20 mg/Kg) and Valsartan (2 mg/Kg)administration improves non-fasting blood glucose levels on days 1through 29.

FIG. 12 is a graph plotting mean blood glucose (mg/dl) levels versustime after first dose (hrs) showing that co-administration of Metformin(150 mg/Kg), Celecoxib (10 or 20 mg/Kg) and Valsartan (2 mg/Kg) improvesoral glucose tolerance in the oral glucose tolerance test (OGTT),wherein the arrow indicates lowering of blood glucose as a result of anincrease in first phase of insulin secretion which is a hallmark ofimprovement in pancreatic beta cell function.

FIG. 13 is a graph plotting OGTT area under the curve (total AUC (0-2 h)showing that co-administration of Metformin (150 mg/Kg), Celecoxib (10or 20 mg/Kg) and Valsartan (2 mg/Kg) administration improves oralglucose tolerance in the OGTT shown as total area under the curve duringthe 2-hour study.

FIG. 14 is a graph plotting mean blood glucose (mg/dl) versus treatmentsshowing that co-administration of Metformin (150 mg/Kg), Celecoxib (10or 20 mg/Kg) and Valsartan (2 mg/Kg) administration improves fastingblood glucose levels. Blood glucose levels were assessed after 5-hourfast prior to the glucose challenge during the OGTT performed on the29th day of the study.

FIG. 15 is a schematic illustration of insulin-dependent blockade ofhepatic gluconeogenesis. Co-treatment with Celecoxib and Valsartanrestores efficacy of Metformin in C57BL/6J DIO mice with hepatic insulinresistance and pancreatic beta cell dysfunction presumably bydisassembling of glucagon-permissive CBP-CREB-TORC2 transcriptioncomplex and by restoring optimal insulin-glucagon molar ratio.

DETAILED DESCRIPTION OF THE INVENTION

Inflammation and RAS play an important pivotal role in Type II diabetesand its comorbidities. Type II diabetes is characterized progressivedeterioration of pancreatic beta cell dysfunction and insulinresistance. Type II diabetes is also characterized by impaired firstphase of insulin secretion due to progressive deterioration ofpancreatic beta cell function which compromises its inherent capacity tocompensate for insulin resistance. Functional response of beta cells andinsulin sensitivity of insulin-responsive tissues such as liver andskeletal muscle are tightly regulated by a feed-back loop. The magnitudeof beta cell response is directly proportional to the tissue sensitivityof insulin-responsive tissues. This feedback loop determines the normalregulation of glucose metabolism and maintenance of glucose homeostasis.Beta cells have an inherent capacity to compensate with an increasedoutput of insulin when insulin resistance is present. Blood glucoselevels rise in the presence of insulin resistance when beta cells areincapable of releasing sufficient insulin due to progressivedeterioration of beta cell function. The Renin-Angiotensin System (RAS)exists in the pancreatic beta cells, and Inflammation and RAS play apivotal role in Type II diabetes and its comorbidities. Angiotensin II(Ang II) is pro-inflammatory in the pancreas and it activatespro-inflammatory cytokine IL-1 beta. Ang II-mediated islet cellinflammation triggers beta cell dysfunction and impairs pancreatic isletcells' inherent capacity for compensating for hyperglycemia. Progressivedeterioration pancreatic islet dysfunction leads to decompensation,pancreatic cell exhaustion and pancreatic beta cell failure (Sauter, N.et al. 2015).

With intense mono- and combination therapies with the existingmodalities, Type II diabetes patients experience progressivedeterioration of metabolic control of glucose homeostasis which isindicative of progressive deterioration of beta cell function in spiteof therapies. Progressive deterioration of metabolic control of glucosehomeostasis in spite of intense treatments with anti-hyperglycemic drugsresults in insulin insufficiency. Blood glucose levels and hepaticgluconeogenesis are tightly regulated by opposing actions of insulin andglucagon. Ant-Inflammatory beta-cell centric methods and formulationsdisclosed are designed to treat pancreatic beta cell dysfunction incombination with insulin resistance by restoring insulin sufficiency aswell as restoring insulin sensitivity for hepatic gluconeogenesis as aresult of optimal insulin-glucagon molar ratio.

The methods and formulations disclosed are aimed at filling the gap thatcurrently exists in the modalities used for the treatment of Type IIdiabetes. The disclosed methods target multiple distinct yet overlappingmechanisms along the immune dysregulation-inflammation-insulinresistance axis that contribute to beta cell dysfunction. The complexetiology of Type II diabetes involves a combination of a variety ofcellular dysfunctions including: white adipocytes, infiltratingmacrophages that contribute to pancreatic beta cell dysfunction whichtriggers insulin resistance. Obesity-triggered inflammation involvesactivation of inducible form of Cyclooxygenase, Cox-2 in tissues such aswhite adipocytes, infiltrating macrophages where as Cox-2 is thepredominant species of Cyclooxygenase expressed in pancreatic beta isletcells. Renin-Angiotensin System (RAS) exists in the islet cells and itsactivation is pro-inflammatory resulting in elevation ofpro-inflammatory cytokines such as IL-1 beta. IL-1 beta-initiated andCox2-mediated elevation in PGE2 induces beta cell apoptosis and reducesbeta cells mass which impairs their inherent capacity to compensate forinsulin resistance.

Development of Type II diabetes in humans is categorized into differentstages or Phases based on the severity of the disease: Prediabetes ischaracterized by post-prandial hyperglycemia, impaired glucose toleranceand decreased sensitivity to insulin, Phase I stage is characterized bybasal as well as post-prandial hyperglycemia along with increasinglydysfunctional insulin-producing pancreatic beta cells and Phase II stageis characterized by significant beta cell hypertrophy and fastinghyperglycemia and Phase III (end stage) patients can no longer produceinsulin and insulin therapy is required (Weir, G. C. et al. 2005). Themethods and formulations disclosed will potentially be efficacious inPrediabetes, Phase I and Phase II patients.

There is extensive cross-talk among signaling pathways associated withchronic low-grade inflammation, innate and adaptive immune systems,glucose and lipid metabolism and they are literally inseparable fromeach other. Based on the preclinical data presented herein together withclinical data previously known to those skilled in the art, efficientclinical management of insulin resistance cannot be achieved by treatingchronic hyperglycemia that occurs due to systemic glucose intolerance inisolation without treating the causative inflammation. Loweringinflammatory parameters, treating pancreatic beta cell dysfunction inaddition to managing hypertension and lowering lipid levels are expectedto contribute to more rapid improvements in CV outcomes with optimal andsustainable glycemic control.

Inflammation-triggered dysfunction of a variety of cell types includinginfiltrated macrophages and white adipocytes contribute toinflammation-initiated pancreatic beta cell dysfunction. (Saltiel, A.(2000) The molecular and physiological basis of insulin resistance:implications for metabolic and cardiovascular diseases. J. Clin. Invest.100 (2): 163-164; Weir, G. C. and S. Bonner-Weir (2004) Five stages ofevolving beta cell dysfunction during progression to diabetes. Diabetes53 (Suppl. 3): S16-S21). Pancreatic beta cell dysfunction triggersinsulin resistance (Del Prato, S and P. Marchetti, 2004).Cyclooxygenase-2 or Cox-2 is the predominant species of Cyclooxyrgenaseexpressed in the pancreatic beta cells (Robertson, R. P. (1998)Dominance of Cyclooxygenase-2 in the regulation of pancreatic isletprostaglandin synthesis. Diabetes 47: 1379-1383). Excessive nutrientintake as well as activation of RAS results in the activation ofCox-2-mediated elevation of PGE2 which leads to islet cell dysfunction(Poitou, V. and R. P. Robertson (2009) Glucolipotoxicity: Fuel excessand beta cell dysfunction. Endocrine Reviews 29(3): 351-366). Beta celldysfunction impairs its inherent capacity for compensating for chronichyperglycemia. If left untreated, beta cells would suffer potentiallyirreversible damage by reaching a state of decompensation and eventuallyto pancreatic exhaustion due to reduction in beta cell mass as a resultof PGE2-mediated apoptosis. When beta cells can no longer produceinsulin, insulin replacement therapy is required (which is acharacteristic of Phase III stage diabetes).

Anti-inflammatory pancreatic beta cell-centric methods disclosed areaimed at treating pancreatic beta islet cell dysfunction in combinationwith insulin resistance by targeting multiple distinct yet overlappingmechanisms along the immune dysregulation-inflammation-insulinresistance axis.

Activation of Renin-Angiotensin System (RAS) in pancreatic beta isletcells has no effect on vasoconstriction and elevation of systolic bloodpressure. Among blockers of Angiotensin II Type 1 receptor (ARBs) suchas Losartan, Irbesartan, Telmisartan, Valsartan etc., only Valsartan (todate) has been shown (by the inventor) to increase insulin sensitivity,improve pancreatic islet function and delay the onset of insulinresistance in human clinical trials.

Pro-inflammatory signals in general and Cox-2-mediated pancreatic celldysfunction in particular play a pivotal role in the development ofinsulin resistance as well as loss of insulin-sensitive regulation ofhepatic gluconeogenesis. Maintenance of normal glucose levels andhepatic gluconeogenesis are tightly controlled by opposing actions ofinsulin secreted by pancreatic beta cells and glucagon pancreatic alphacells. Metformin, the current first line of therapy for overt Type IIdiabetes improves blood glucose levels by primarily blocking hepaticgluconeogenesis.

Obesity in general and obesity-triggered low-grade or sub-acute chronicinflammation is the major contributing factor for systemic insulinresistance, systemic glucose intolerance and systemic lipotoxicity (Xu,H. 2013). Extensive signaling cross-talk among inflammatory signalingpathways, innate and adaptive immune systems, glucose metabolic pathwaysand lipid metabolism pathways in a temporal as well as contextual mannerinitiate and sustain impaired glucose homeostasis (Shu, C. J. et al.2012). The events that initiate and maintain inflammation is central tothe complex pathophysiology of obesity-triggered insulin resistanceinclude the following: As the primary tissue for storage of fat, whiteadipose tissue (WAT) undergoes hyperplasia as preadipocytesdifferentiate into adipocytes and maintains an anti-inflammatory stateacting as a sink with a buffering capacity for fat intake and fat influx(Tateya, S. et al. 2013). The buffering capacity of WAT prevents ectopicfat accumulation and consequently from lipotoxicity (Saltiel, A. 2000).The resident M2 macrophages of hyperplasic WAT secrete anti-inflammatorycytokines such as IL-10, IL-4 and IL-13. The buffering capacity for fatintake in obese patients without insulin resistance occurs as a resultof suppression of release of non-esterified fatty acids, decrease in theactivity of HSL (Hormone-sensitive lipase) and ATGL (Adiposetriglyceride Lipase) (Mitrou, P. et al. 2013). Hyperplasic WAT also havethe capacity for increased clearance of triacyl glycerol due to increasein the activity of Lipoprotein lipase (LPL). As white adipocytesaccumulate more triacyl glycerol as a result of longterm nutrientexcess, they become hypertorphic by increasing in size with concomitantrelease of monocyte chemoattractant protein (MCP-1) which creates agradience for recruitment and infiltration of circulatingpro-inflammatory M1 macrophages into WAT as shown in FIG. 2 byimmunostaining of sections of WAT with macrophagee surface marker F4/80(Coenen, K. R. et al. 2007). Infiltrated M1 macrophages are retained inWAT due to the synthesis of a guidance molecule known as Netrin-1.Deletion of Netrin-1 results in emigration of infiltrated macrophages ina diet-induced obesity mouse model and improves insulin sensitivity(Ramkhelawon, B. et al. 2014). As the number of M1 macrophages increase,the WAT gradually shifts from an anti-inflammatory state into apro-inflammatory state as a result of secretion of pro-inflammatorycytokines and chemokines such as IL-6, TNF-alpha, IL-1beta, IL-18, CCL2,CCL3, CXCL8, C-reactive protein (CRP) (Quatanami, M. and Lazar, M. A.2007). WAT gradually loses its inherent buffering capacity for fatintake and it shifts to a pro-inflammatory state. Elevation in thelevels of pro-inflammatory cytokines increases activity of JNK-1 whichphosphorylates serine residues on IRS-1 (Insulin receptor substrate-1)rendering it incapable of triggering cascade of signaling events furtherdownstream from IRS-1 in insulin sensitive tissues such as adipocytes,skeletal muscle and hepatocytes. Gradual development of systemic insulinresistance contributes to systemic glucose intolerance as a result of anumber of events including: decrease in the levels of adiponectin, Glut4and IL-10, activation of toll-like receptor, TLR-4 as well as activationof the receptor for Palmitic acid, UNC5b, increase in the levels ofleptin, resistin, visfatin and Netrin-1, increase in the levels of PGEmetabolites as well as an increase in the level of oxidative stressparameters, pancreatic beta cell dysfunction, activation of SOC(1,2,3)-mediated phosphorylation of IRS-1 and IRS-2, increase in thedegradation of IRS-1 and IRS-2, decrease in the levels of thermogenicgenes, PGC-1 and UCP-1, and an increase in NLRP3 inflammasome, caspase-1and ASC (Wang, X. et al. 2014, Boucher, J. et al. 2014). Development ofinsulin resistance contributes to a decrease in the amount ofintracellular glucose which results in elevated levels of blood glucoselevels and an increase in the release of non-esterified fatty acid fromWAT which results in elevation of circulating levels of free fatty acids(FFA) and triglycerides (TG). It is an established fact thatinflammation is central to the complex pathophysiology of not only T2DMand it is also central to the etiology of diabetes-relatedcomplications. As a result of systemic glucose intolerance, Type IIdiabetes patients develop systemic glucolipotoxicity.

Infiltration of circulating M1 macrophages in to the White adiposetissue (WAT) is one of the early events in shifting the WAT from ananti-inflammatory state to an inflammatory state. Comparison of WAT froma lean animal with that of an obese animal is shown in FIG. 2. Sectionsof WAT are immunostained with a macrophage-specific marker F4/80(Coenen, K. R. et a. 2007). Macrophages are shown in red.

Inflammation is the underlying cause of the pathophysiology of not onlyinsulin resistance but also a critical contributing factor to thecomorbidities such as hypertension, dyslipidemia and obesity. Thecomplex pathophysiology of the metabolic syndrome is illustrated in FIG.3. Activation of inducible Cyclooxygenase, Cox-2 or activation ofconstitutive Cox-2 plays a critically important role in the initiationof obesity-triggered inflammation. A link between elevation of bloodglucose levels and activation of Cox-2 in pancreatic beta cells is wellestablished (Oshima, H. et al. 2006). C57BL/6J DIO (Diet-inducedobesity) mice are an established polygenic preclinical translationalmodel for Type II diabetes, prediabetes, glucose intolerance and insulinresistance. Selective deletion of Cox-2 improves glucose tolerance afterglucose loading (2 g/Kg) after fasting mice for 6 hours in anintraperitoneal glucose tolerance test (IPGTT) as shown FIG. 4 (Fujita,H. et al. 2007). Blood samples were taken from the cavernous sinus bycapillary under anesthetized condition at 0.5 h before (0 h in thefigure) and at 0.5, 1, 2 and 5 h after glucose loading. Blood glucosewas measured using Glucord Diameter. (Arkray, Tokyo, Japan).

Cox-2 is the predominant species of cyclooxygenase expressed pancreaticbeta islet cells. Excessive nutrient intake as well as activation of RASresults in the activation of Cox-2. Cox-2-mediated elevation in PGE2impairs pancreatic compensation and leads to islet cell dysfunction(Poitout, V and Robertson, R. P. 2008). Elevation in PGE2 levelscontributes to reduction beta islet cell mass due to decreasedhyperplasia as well as due to apoptosis of the beta islet cells. Asshown in FIG. 5, selective Cox-2 inhibition reduces HbA1c levels byabout 0.4%. SC58560 and SC58236 are selective Cox-1 and Cox-2 inhibitorsrespectively (Fujita, H. et al. 2007). HbA1c levels were determinedusing a DCA 2000 Analyzer (Bayer, Elkhart, Ind.).

Selective inhibition of Cox-2 improves glucose tolerance in anintraperitoneal glucose tolerance test (IPGTT) and elevates plasmainsulin levels as shown in FIG. 6 (Fujita, H. et al. 2007). IPGTT wasperformed after mice were fasted for 6 hours. After glucose loading (2g/Kg), blood samples were taken from the cavernous sinus by capillaryunder anesthetized condition at 0.5 h before (0 h in the figure) and at0.5, 1, 2 and 5 h. Blood glucose was measured using Glucord Diameter.(Arkray, Tokyo, Japan). Plasma insulin levels after glucose injectionwere measured using a commercial insulin ELISA kit (Morinaga, Yokohama,Japan).

Non-alcoholic staeatohepatitis (NASH) is a condition that coexists withType II diabetes. Celecoxib, a selective Cox-2 inhibitor reversessteatohepatitis and inflammation in Wistar rat NASH model (Chen, J. etal. 2011). FIG. 7 shows the histological changes in the liver of rats onHFD (high fat diet) and Celecoxib-treated rats. Rats on normal diet wereused as controls. A. Wistar rats on normal diet for 4 weeks showednormal liver histology, (B) When rats fed the HFD for 4 weeks, fatdroplets and small groups of inflammatory cells (arrow) were observed.(C) After 8 weeks of HFD feeding, severity of steatohepatitis greatlyincreased. (D) Treatment of HFD rats with Celecoxib (20 mg/kg/day) for 4weeks attenuated steatohepatitis. Arrows point to fat droplets andgroups of inflammatory cells. Sections of liver were stained with eosinand hematoxylin.

Metformin, a biguanide is the gold standard among the currently marketedType II diabetes drugs. As shown in FIG. 8, it improves glucosetolerance in C57BL/6J diet-induced obese (DIO) mice model in oralglucose tolerance test (OGTT) in which the mice were challenged with 2g/Kg body weight glucose after fasting mice for 20 hours (Matsui, Y. etal. 2010). 0.25% and 0.5% Metformin are 150 mg/Kg/day and 300 mg/Kg/dayrespectively. Plasma glucose levels were determined by using GlucoseII-Test Wako purchased from Wako Pure Chemical Industries, Ltd. (Osaka,Japan).

Valsartan (Diovan) is a selective Angiotensin receptor Type I receptorblocker (ARB). RAS play a critically important role ininflammation-induced beta islet cell dysfunction as well in the processof pancreatic decompensation. Valsartan has been shown to delay theonset of Type II diabetes in prediabetes patients as well (Andraws, R.and D. L. Brown, 2007). In a randomized controlled, double blind,two-center clinical study conducted for 26 weeks, Valsartan improvedbeta cells function and insulin sensitivity in subjects with impairedglucose metabolism (Van der Zijl, N. et al. 2011). As shown in FIG. 8,Valsartan improves glucose tolerance in C57BL/6J diet-induced obese(DIO) mice. For testing glucose tolerance, mice were fasted overnightand then injected intraperitoneally (IP) with 2 g/Kg glucose. Bloodglucose measurements were performed with an UltraTouch glucometer usingblood samples taken from cut tail tips at baseline, 15, 30, 45 and 60minutes after the injection of glucose (Cole, B. K. et al. 2010).

The results described herein suggest when the leading anti-hyperglycemicdrug such as Metformin becomes inefficacious due to insulininsufficiency as a result of pancreatic beta cell insufficiency,co-treatment with sub-therapeutic dose of Celecoxib and sub-systolicblood pressure dose of Valsartan restores insulin sufficiency bytreating pancreatic beta cell dysfunction. The results described hereinfurther suggest that the anti-inflammatory pancreatic beta cell-centricproduct combination has the potential for a future standard of care forobesity-triggered cancers such as breast cancer, non-alcoholicsteatohepatitis (NASH), non-alcoholic fatty liver disease (NAFLD),obstructive sleep apnea, thrombotic diseases such as myocardialinfarction (MI) and ischemic stroke, polycystic ovarian disease anddiabetic neuropathy. Further, the results described herein suggest thatthe anti-inflammatory pancreatic beta cell-centric product combinationhas the potential for a future standard of care for conditions thatcoexist with Type II diabetes such as osteoarthritis (OA), rheumatoidarthritis (RA), non-alcoholic steatohepatitis (NASH), non-alcoholicfatty liver disease (NAFLD), and obstructive sleep apnea.

None of the drugs that are currently on the market prevent, delay orrestore progressive deterioration of pancreatic beta cells. Innovativeand novel anti-inflammatory beta-cell centric methods and formulationsthat are disclosed here are aimed at treating beta cell dysfunction,restore insulin sufficiency and maintain its inherent capacity tocompensate for insulin resistance. The novel and innovative combinationof Metformin, Celecoxib and Valsartan has the distinguishing property ofrestoring the inherent capacity of pancreatic beta cells to compensatefor insulin resistance by treating beta cell dysfunction.

Methods and processes involved in the preparation of tablets, capsulesand tablets inside a capsule will be improved and optimized for the FDCformulations described and disclosed in this application. Dosing ofgranules for the bottom layer will be placed in the rotary die from thefirst hopper followed by recompression of the first layer by the firstroller. The first layer will be reduced to a smaller size to createspace required for the second feeder. Dosing of the top layer wouldoccur from the second hopper to the rotary die. The filled die will betransferred to the second roller for compression. Final compression ofthe two layers would result in two distinct layers. Multilayer tabletmachines will be equipped with suction nozzles or dust extractor toremove fine powder granules to eliminate cross-contamination between thetwo layers.

A therapeutic dose of an anti-inflammatory drug will be combined withtherapeutic doses of one or more anti-type II diabetic,anti-hypertensive, lipid lowering and anti-obesity drugs withpredetermined modified release kinetics to achieve therapeutic as wellas kinetic synergies.

Therapeutic doses of a combination of anti-inflammatory drugs, anti-typeII diabetes drugs, lipid lowering drugs and anti-obesity drugs will beformulated in the form of fixed dose combination products (FDC) to treatType II diabetes patients who are stratified into groups based on theircardiometabolic risk factor profiles.

Therapeutic doses of a combination of anti-inflammatory drugs, anti-typeII diabetes drugs, lipid lowering drugs and anti-obesity drugs will beformulated in the form of fixed dose combination products (FDC) to treatType II diabetes patients who are stratified into groups for lackadequate therapeutic efficacy and over all clinical benefit from theprior treatments.

Therapeutic doses of a combination of anti-inflammatory drugs, anti-typeII diabetes drugs, lipid lowering drugs and anti-obesity drugs will beformulated in the form of fixed dose combination products (FDC) toprevent or delay the onset of Type II diabetes in Prediabetes patients.

FDC formulations contain the following combinations in the form ofsingle layer monolithic tablet or multi-layered monolithic tablet or inthe form of a core tablet-in-tablet or multi-layered multi-disk tabletor beads inside a capsule or tablets inside a capsule but not limitedto: (a) therapeutically efficacious Fixed Dose Combinations (FDC) of IRformulations of different drugs; (b) Therapeutically efficacious FDC ofIR and ER formulations of different drugs; Therapeutically efficaciousFDC of IR and ER formulations of the same drug in combinations with ERformulations of one or more of different drugs; Therapeuticallyefficacious FDC of IR and ER formulations of the same drug incombinations with ER formulations of one or more of the same drug;and/or Therapeutically efficacious FDC of IR and ER formulations of thesame drug in combinations with ER formulations of one or more ofdifferent drugs to compensate for potential adverse side effects such ashypoglycemia.

Preparation of FDC Formulations

Methods and compositions to treat metabolic and cardiovascular diseaseshave been described in general in several issued patents and patentapplications such as U.S. Pat. Nos. 5,561,165, 8,431,522, 7,632,818,8,586,607, 8,759,334, 8,586,529, 6,846,800, 8,507,451, 5,190, 970, U.S.Pat. No. 8,586,069 B2, U.S. Pat. No. 8,435,550 B2, WO 2008014471 A1,U.S. Pat. No. 8,367,418 B2, WO 2004017896 A2, U.S. Pat. No. 8,008,328B2, WO 2010088375 A2, US 20130261092 A1, US 20140037739 A1, WO2005009412 A1, EP 2727587 A1 and WO 2011 078993.

Tablets of the invention described here can be prepared by methods wellknown in the art. Various methods for IR, QR, ER, SR, XR, DR layers andthe vehicles therein are well known in the art. Generally recognizedcompendium of methods include: Remington: The Science and Practice ofPharmacy, Alfonso R. Gennaro, Editor, 20th Edition, Lippinscott Williams& Wilkins, Philadelphia, Pa.; Sheth et al. (1980) Compressed tablets, inPharmaceutical dosage forms, Vol 1, edited by Lieberman and Lachtman,Dekker, NY.

Published methods (Shende, P. et al. 2012; Khan, Z. et al. 2013) will beoptimized further to generate delivery systems in the form of FDCformulations.

For oral, buccal, and sublingual administration, powders, suspensions,granules, tablets, pills, capsules, gelcaps, and caplets are acceptableas solid dosage forms.

These can be prepared, for example, by mixing one or more compounds ofthe instant present technology, or pharmaceutically acceptable salts ortautomers thereof, with at least one additive such as a starch or otheradditive. Suitable additives are sucrose, lactose, cellulose sugar,mannitol, maltitol, dextran, starch, agar, alginates, chitins,chitosans, pectins, tragacanth gum, gum arabic, gelatins, collagens,casein, albumin, synthetic or semi-synthetic polymers or glycerides.Optionally, oral dosage forms can contain other ingredients to aid inadministration, such as an inactive diluent, or lubricants such asmagnesium stearate, or preservatives such as paraben or sorbic acid, oranti-oxidants such as ascorbic acid, tocopherol or cysteine, adisintegrating agent, binders, thickeners, buffers, sweeteners,flavoring agents or perfuming agents. Tablets and pills may be furthertreated with suitable coating materials known in the art.

Liquid dosage forms for oral administration may be in the form ofpharmaceutically acceptable emulsions, syrups, elixirs, suspensions, andsolutions, which may contain an inactive diluent, such as water.Pharmaceutical formulations and medicaments may be prepared as liquidsuspensions or solutions using a sterile liquid, such as, but notlimited to, an oil, water, an alcohol, and combinations of thesepharmaceutically suitable surfactants, suspending agents, emulsifyingagents, may be added for oral or parenteral administration. As notedabove, suspensions may include oils. Such oils include, but are notlimited to, peanut oil, sesame oil, cottonseed oil, corn oil and oliveoil. Suspension preparation may also contain esters of fatty acids suchas ethyl oleate, isopropyl myristate, fatty acid glycerides andacetylated fatty acid glycerides. Suspension formulations may includealcohols, such as, but not limited to, ethanol, isopropyl alcohol,hexadecyl alcohol, glycerol and propylene glycol. Ethers, such as butnot limited to, poly(ethyleneglycol), petroleum hydrocarbons such asmineral oil and petrolatum; and water may also be used in suspensionformulations.

Immediate release formulations will be prepared by combining superdisintegrant such as Croscarmellose sodium and different grades ofmicrocrystalline cellulose in different ratios. To aid disintegration,sodium starch glycolate will be added. A formulation method which wouldresult in tablet disintegration of >98% in less than a minute will beused in the final formulation.

Published methods will be used to prepare FDC of drugs either in theform of a form of beads inside a capsule. Each bead would representdifferent color and coating level depending on the kinetics of drugrelease. For example, some beads would release drugs immediately (IR).Some would beads would release for an extended period of time (ER),while some after a long while (DR).

As an example, extended release multi-layered matrix tablets will beprepared by using FDC of different drugs and hydrophilic polymer ratiowith guar gum, hydroxypropylmethyl cellulose, and xanthan gum as matrixformers. All lubricated formulations will be compressed by wetgranulation method.

Multilayer tablet delivery procedure used in the GeoMatrix™ Technologywill be used. It consists of a hydrophilic matrix core, containing theactive ingredient, and one or two impermeable or semi-permeablepolymeric coatings. This technology uses films or compressed polymericbarrier coatings on one or both sides of the core.

The presence of polymeric coatings in the GeoMatrix™ Technology,modifies the hydration/swelling rates of the core and reduces thesurface area available for drug release. These partial coatings providea modulation of the drug dissolution profile: they reduce the releaserate from the device and shift the typical time-dependent release ratetowards constant release. This technology enables customized levels ofcontrolled release of specific drugs and/or simultaneous release of twodifferent drugs at different rates can be achieved from a single tablet.The combination of layers, each with different rates of swelling,gelling and erosion, is used for the rate of drug release in the body.Exposure of the multilayer tablet as a result of partial coating mayaffect the release and erosion rates, therefore, transformation ofmultilayered tablet with exposure on all sides to the gastrointestinalfluids upon detachment of the barrier layer will be considered.

Multi-layered tablets containing combinations of immediate release andmodified/extended release of two different drugs or dual release rate ofthe same drug in a single dosage form will be prepared by usinghydrophilic and hydrophobic polymer matrices.

Dual release repeat action multi-layered tablets will be prepared withan outer compression layer with an initial dose of rapidlydisintegrating matrix in the stomach and a core inner layer tabletformulated with components that are insoluble in the gastric media butrelease efficiently in the intestinal environment.

Cross-contamination between different layers will be prevented by usingbarrier layers of inert/non-functional material.

Quality control methods and best industry practices will be developedand adopted to meet international Pharmacopeial standards.

Multilayered matrix tablets of a combination of immediate and/orextended release tablets will be evaluated for a number ofphysico-chemical properties (Khan, Z. et al. 2013)

-   -   a) Uniformity of weight    -   b) Content of active ingredient/drug content    -   c) Friability    -   d) Hardness    -   e) Thickness    -   f) Weight uniformity    -   g) Disintegration time    -   h) In vitro drug release/dissolution    -   i) Stability

Compositions containing the active agent(s) of the present invention canbe formulated for administration to a subject via any conventional meansincluding, but not limited to, oral, parenteral (e.g., intravenous,subcutaneous, or intramuscular), buccal, intranasal or transdermaladministration routes.

Moreover, the pharmaceutical compositions described herein can beformulated into any suitable dosage form, including but not limited to,aqueous oral dispersions, aqueous oral suspensions, solid dosage formsincluding oral solid dosage forms, aerosols, controlled releaseformulations, fast melt formulations, effervescent formulations,self-emulsifying dispersions, solid solutions, liposomal dispersions,lyophilized formulations, tablets, capsules, pills, powders, delayedrelease formulations, immediate release formulations, modified releaseformulations, extended release formulations, pulsatile releaseformulations, multiparticulate formulations, and mixed immediate releaseand controlled release formulations. In some embodiments, the activeagent(s) of the present invention formulations provide a therapeuticallyeffective amount of the active agent(s) of the present invention over aninterval of about 30 minutes to about 8 hours after administration,enabling, for example, once-a-day, twice-a-day (b.i.d.), or three timesa day (t.i.d.) administration if desired. In one embodiment, the activeagent(s) of the present invention particles are formulated into acontrolled release or pulsatile solid dosage form for b.i.d.administration. In other embodiments, the active agent(s) of the presentinvention particles are dispersed in an aqueous dispersion for b.i.d.administration. Generally speaking, one will desire to administer anamount of the active agent(s) of the present invention that is effectiveto achieve a plasma level commensurate with the concentrations found tobe effective in vivo for a period of time effective to elicit a desiredtherapeutic effect.

The various release dosage formulations discussed above can becharacterized by their disintegration profile. A profile ischaracterized by the test conditions selected. Thus the disintegrationprofile can be generated at a pre-selected apparatus type, shaft speed,temperature, volume, and pH of the dispersion media. Severaldisintegration profiles can be obtained. For example, a firstdisintegration profile can be measured at a pH level approximating thatof the stomach (about pH 1.2); a second disintegration profile can bemeasured at a pH level approximating that of one point in the intestineor several pH levels approximating multiple points in the intestine(about 6.0 to about 7.5, more specifically, about 6.5 to 7.0). Anotherdisintegration profile can be measured using distilled water. Therelease of formulations may also be characterized by theirpharmacokinetic parameters, for example, Cmax, Tmax, and AUC (0-τ).

In one embodiment, the dosage form is a solid oral dosage form which isan immediate release dosage form whereby >80% of the active agent(s) ofthe present invention particles hours after administration. In otherembodiments, the invention provides an (e.g., solid oral) dosage formthat is a controlled release or pulsatile release dosage form. In suchinstances, the release may be, e.g., 30 to 60% of the active agent(s) ofthe present invention particles by weight are released from the dosageform within about 2 hours after administration and about 90% by weightof the active agent(s) of the present invention released from the dosageform within about 7 hours after administration. In yet otherembodiments, the dosage form includes at least one active agent inimmediate release form and at least one active agent in delayed releaseform, or sustained release form. In yet other embodiments, the dosageform includes at least two active agents which are released at differentrates as determined by in-vitro dissolution testing or via oraladministration.

In some embodiments, the solid dosage forms of the present invention maybe in the form of a tablet, (including a suspension tablet, a fast-melttablet, a bite-disintegration tablet, a rapid-disintegration tablet, aneffervescent tablet, or a caplet), a pill, a powder (including a sterilepackaged powder, a dispensable powder, or an effervescent powder), acapsule (including both soft or hard capsules, e.g., capsules made fromanimal-derived gelatin or plant-derived HPMC, or “sprinkle capsules”),solid dispersion, solid solution, bioerodible dosage form, controlledrelease formulations, pulsatile release dosage forms, multiparticulatedosage forms, pellets, granules, or an aerosol. In other embodiments,the pharmaceutical formulation is in the form of a powder. In stillother embodiments, the pharmaceutical formulation is in the form of atablet, including but not limited to, a fast-melt tablet. Additionally,pharmaceutical formulations of the present invention may be administeredas a single capsule or in multiple capsule dosage form. In someembodiments, the pharmaceutical formulation is administered in two, orthree, or four, capsules or tablets.

In some embodiments, solid dosage forms, e.g., tablets, effervescenttablets, and capsules, are prepared by mixing the active agent(s) of thepresent invention particles with one or more pharmaceutical excipientsto form a bulk blend composition. When referring to these bulk blendcompositions as homogeneous, it is meant that the active agent(s) of thepresent invention particles are dispersed evenly throughout thecomposition so that the composition may be readily subdivided intoequally effective unit dosage forms, such as tablets, pills, andcapsules. The individual unit dosages may also comprise film coatings,which disintegrate upon oral ingestion or upon contact with diluents.These the active agent(s) of the present invention formulations can bemanufactured by conventional pharmaceutical techniques.

Conventional pharmaceutical techniques for preparation of solid dosageforms include, e.g., one or a combination of methods: (1) dry mixing,(2) direct compression, (3) milling, (4) dry or non-aqueous granulation,(5) wet granulation, or (6) fusion. See, e.g., Lachman et al., Theoryand Practice of Industrial Pharmacy (1986). Other methods include, e.g.,spray drying, pan coating, melt granulation, granulation, fluidized bedspray drying or coating (e.g., wurster coating), tangential coating, topspraying, tableting, extruding and the like.

The pharmaceutical solid dosage forms described herein can comprise theactive agent(s) of the present invention compositions described hereinand one or more pharmaceutically acceptable additives such as acompatible carrier, binder, complexing agent, ionic dispersionmodulator, filling agent, suspending agent, flavoring agent, sweeteningagent, disintegrating agent, dispersing agent, surfactant, lubricant,colorant, diluent, solubilizer, moistening agent, plasticizer,stabilizer, penetration enhancer, wetting agent, anti-foaming agent,antioxidant, preservative, or one or more combination thereof. In stillother aspects, using standard coating procedures, such as thosedescribed in Remington's Pharmaceutical Sciences, 20th Edition (2000), afilm coating is provided around the active agent(s) of the presentinvention formulation. In one embodiment, some or all of the activeagent(s) of the present invention particles are coated. In anotherembodiment, some or all of the active agent(s) of the present inventionparticles are microencapsulated. In yet another embodiment, some or allof the active agent(s) of the present invention is amorphous materialcoated and/or microencapsulated with inert excipients. In still anotherembodiment, the active agent(s) of the present invention particles notmicroencapsulated and are uncoated.

Suitable carriers for use in the solid dosage forms described hereininclude, but are not limited to, acacia, gelatin, colloidal silicondioxide, calcium glycerophosphate, calcium lactate, maltodextrin,glycerin, magnesium silicate, sodium caseinate, soy lecithin, sodiumchloride, tricalcium phosphate, dipotassium phosphate, sodium stearoyllactylate, carrageenan, monoglyceride, diglyceride, pregelatinizedstarch, hydroxypropylmethylcellulose, hydroxypropylmethylcelluloseacetate stearate, sucrose, microcrystalline cellulose, lactose, mannitoland the like.

Suitable filling agents for use in the solid dosage forms describedherein include, but are not limited to, lactose, calcium carbonate,calcium phosphate, dibasic calciumphosphate, calcium sulfate,microcrystalline cellulose (e.g., Avicel®, Avicel® PH101, Avicel® PH102,Avicel® PH105, etc.), cellulose powder, dextrose, dextrates, dextran,starches, pregelatinized starch, hydroxypropylmethylcellulose (HPMC),hydroxypropylmethylcellulose phthalate, hydroxypropylmethylcelluloseacetate stearate (HPMCAS), sucrose, xylitol, lactitol, mannitol,sorbitol, sodium chloride, polyethylene glycol, and the like.

If needed, suitable disintegrants for use in the solid dosage formsdescribed herein include, but are not limited to, natural starch such ascorn starch or potato starch, a pregelatinized starch such as National1551 or Amijel®, or a sodium starch glycolate such as Promogel® orExplotab®, a cellulose such as a wood product, microcrystallinecellulose, e.g., Avicel®, Avicel® PH101, Avicel® PH102, Avicel® PH105,Elcema® P100, Emcocel®, Vivacel®, Ming Tia®, and Solka-Floc®, Ac-Di-Sol,methylcellulose, croscarmellose, or a cross-linked cellulose, such ascross-linked sodium carboxymethylcellulose (Ac-Di-Sol®), cross-linkedcarboxymethylcellulose, or cross-linked croscarmellose, a cross-linkedstarch such as sodium starch glycolate, a cross-linked polymer such ascrosspovidone, a cross-linked polyvinylpyrrolidone, alginate such asalginic acid or a salt of alginic acid such as sodium alginate, a claysuch as Veegum® HV (magnesium aluminum silicate), a gum such as agar,guar, locust bean, Karaya, pectin, or tragacanth, sodium starchglycolate, bentonite, a natural sponge, a surfactant, a resin such as acation-exchange resin, citrus pulp, sodium lauryl sulfate, sodium laurylsulfate in combination starch, and the like.

Binders impart cohesiveness to solid oral dosage form formulations: forpowder filled capsule formulation, they aid in plug formation that canbe filled into soft or hard shell capsules and in tablet formulation,binders ensure that the tablet remains intact after compression and helpassure blend uniformity prior to a compression or fill step. Materialssuitable for use as binders in the solid dosage forms described hereininclude, but are not limited to, carboxymethylcellulose, methylcellulose(e.g., Methocel®), hydroxypropylmethylcellulose (e.g. Hypromellose USPPharmacoat-603, hydroxypropylmethylcellulose acetate stearate (AqoateHS-LF and HS), hydroxyethylcellulose, hydroxypropylcellulose (e.g.,Klucel®), ethylcellulose (e.g., Ethocel®), and microcrystallinecellulose (e.g., Avicel®), microcrystalline dextrose, amylose, magnesiumaluminum silicate, polysaccharide acids, bentonites, gelatin,polyvinylpyrrolidone/vinyl acetate copolymer, crosspovidone, povidone,starch, pregelatinized starch, tragacanth, dextrin, a sugar, such assucrose (e.g., Dipac®), glucose, dextrose, molasses, mannitol, sorbitol,xylitol (e.g., Xylitab®), lactose, a natural or synthetic gum such asacacia, tragacanth, ghatti gum, mucilage of isapol husks, starch,polyvinylpyrrolidone (e.g., Povidone® CL, Kollidon® CL, Polyplasdone®XL-10, and Povidone® K-12), larch arabogalactan, Veegum®, polyethyleneglycol, waxes, sodium alginate, and the like. In general, binder levelsof 20-70% are used in powder-filled gelatin capsule formulations. Binderusage level in tablet formulations is a function of whether directcompression, wet granulation, roller compaction, or usage of otherexcipients such as fillers which itself can act as moderate binder areused. Formulators skilled in art can determine the binder level for theformulations, but binder usage level of up to 70% in tablet formulationsis common.

Suitable lubricants or glidants for use in the solid dosage formsdescribed herein include, but are not limited to, stearic acid, calciumhydroxide, talc, corn starch, sodium stearyl fumarate, alkali-metal andalkaline earth metal salts, such as aluminum, calcium, magnesium, zinc,stearic acid, sodium stearates, magnesium stearate, zinc stearate,waxes, Stearowet®, boric acid, sodium benzoate, sodium acetate, sodiumchloride, leucine, a polyethylene glycol or a methoxypolyethylene glycolsuch as Carbowax™, PEG 4000, PEG 5000, PEG 6000, propylene glycol,sodium oleate, glyceryl behenate, glyceryl palmitostearate, glycerylbenzoate, magnesium or sodium lauryl sulfate, and the like.

Suitable diluents for use in the solid dosage forms described hereininclude, but are not limited to, sugars (including lactose, sucrose, anddextrose), polysaccharides (including dextrates and maltodextrin),polyols (including mannitol, xylitol, and sorbitol), cyclodextrins andthe like.

Non water-soluble diluents are compounds typically used in theformulation of pharmaceuticals, such as calcium phosphate, calciumsulfate, starches, modified starches and microcrystalline cellulose, andmicrocellulose (e.g., having a density of about 0.45 g/cm3, e.g. Avicel,powdered cellulose), and talc.

Suitable wetting agents for use in the solid dosage forms describedherein include, for example, oleic acid, glyceryl monostearate, sorbitanmonooleate, sorbitan monolaurate, triethanolamine oleate,polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitanmonolaurate, quaternary ammonium compounds (e.g., Polyquat 10®), sodiumoleate, sodium lauryl sulfate, magnesium stearate, sodium docusate,triacetin, vitamin E TPGS and the like. Wetting agents includesurfactants.

Suitable surfactants for use in the solid dosage forms described hereininclude, for example, docusate and its pharmaceutically acceptablesalts, sodium lauryl sulfate, sorbitan monooleate, polyoxyethylenesorbitan monooleate, polysorbates, polaxomers, bile salts, glycerylmonostearate, copolymers of ethylene oxide and propylene oxide, e.g.,Pluronic® (BASF), and the like.

Suitable suspending agents for use in the solid dosage forms describedhere include, but are not limited to, polyvinylpyrrolidone, e.g.,polyvinylpyrrolidone K12, polyvinylpyrrolidone K17, polyvinylpyrrolidoneK25, or polyvinylpyrrolidone K30, polyethylene glycol, e.g., thepolyethylene glycol can have a molecular weight of about 300 to about6000, or about 3350 to about 4000, or about 7000 to about 18000, vinylpyrrolidone/vinyl acetate copolymer (S630), sodium alginate, gums, suchas, e.g., gum tragacanth and gum acacia, guar gum, xanthans, includingxanthan gum, sugars, cellulosics, such as, e.g., sodiumcarboxymethylcellulose, methylcellulose, sodium carboxymethylcellulose,hydroxypropylmethylcellulose, hydroxyethylcellulose, polysorbate-80,polyethoxylated sorbitan monolaurate, polyethoxylated sorbitanmonolaurate, povidone and the like.

Suitable antioxidants for use in the solid dosage forms described hereininclude, for example, e.g., butylated hydroxytoluene (BHT),butylhydroxyanisole (BHA), sodium ascorbate, Vitamin E TPGS, ascorbicacid, sorbic acid and tocopherol.

The above-listed additives should be taken as merely exemplary, and notlimiting, of the types of additives that can be included in solid dosageforms of the present invention. The amounts of such additives can bereadily determined by one skilled in the art, according to theparticular properties desired.

Compressed tablets are solid dosage forms prepared by compacting thebulk blend the active agent(s) of the present invention formulationsdescribed above. In various embodiments, compressed tablets which aredesigned to dissolve in the mouth will comprise one or more flavoringagents. In other embodiments, the compressed tablets will comprise afilm surrounding the final compressed tablet. In some embodiments, thefilm coating can provide a delayed release of the active agent(s) of thepresent invention formulation. In other embodiments, the film coatingaids in patient compliance (e.g., Opadry® coatings or sugar coating).Film coatings comprising Opadry® typically range from about 1% to about3% of the tablet weight. Film coatings for delayed release usuallycomprise 2-6% of a tablet weight or 7-15% of a spray-layered beadweight. In other embodiments, the compressed tablets comprise one ormore excipients.

A capsule may be prepared, e.g., by placing the bulk blend the activeagent(s) of the present invention formulation, described above, insideof a capsule. In some embodiments, the active agent(s) of the presentinvention formulations (non-aqueous suspensions and solutions) areplaced in a soft gelatin capsule. In other embodiments, the activeagent(s) of the present invention formulations are placed in standardgelatin capsules or non-gelatin capsules such as capsules comprisingHPMC. In other embodiments, the active agent(s) of the present inventionformulations are placed in a sprinkle capsule, wherein the capsule maybe swallowed whole or the capsule may be opened and the contentssprinkled on food prior to eating. In some embodiments of the presentinvention, therapeutic dose is split into multiple (e.g., two, three, orfour) capsules. In some embodiments, the entire dose of the activeagent(s) of the present invention formulation is delivered in a capsuleform. For example, the capsule may comprise between about 100 mg toabout 600 mg of the active agent(s) of the present invention. In someembodiments, the capsule may comprise between about 100 to about 500 mgof the active agent(s) of the present invention. In other embodiments,capsule may comprise about 300 mg to about 400 mg of the active agent(s)of the present invention.

Another useful capsule has a shell comprising the material of therate-limiting membrane, including any of the coating materialspreviously discussed, and filled with the active agent(s) of the presentinvention particles. A particular advantage of this configuration isthat the capsule may be prepared independently of the active agent(s) ofthe present invention particles, thus process conditions that wouldadversely affect the drug can be used to prepare the capsule. Apreferred embodiment is a capsule having a shell made of a porous or apH-sensitive polymer made by a thermal forming process. An especiallypreferred embodiment is a capsule shell in the form of an asymmetricmembrane; i.e., a membrane that has a thin skin on one surface and mostof whose thickness is constituted of a highly permeable porous material.A preferred process for preparation of asymmetric membrane capsulescomprises a solvent exchange phase inversion, wherein a solution ofpolymer, coated on a capsule-shaped mold, is induced to phase-separateby exchanging the solvent with a miscible non-solvent.

In yet another embodiment, spray layered active agent(s) of the presentinvention particles are filled in a capsule. An exemplary process formanufacturing the spray layered the active agent(s) of the presentinvention is the fluidized bed spraying process. The active agent(s) ofthe present invention suspensions or the active agent(s) of the presentinvention complex suspensions described above are sprayed onto sugar ormicrocrystalline cellulose (MCC) beads (20-35 mesh) with Wurster columninsert at an inlet temperature of 50° C. to 60° C. and air temp of 30°C. to 50° C. A 15 to 20 wt % total solids content suspension containing45 to 80 wt % the active agent(s) of the present invention, 10 to 25 wt% hydroxymethylpropylcellulose, 0.25 to 2 wt % of SLS, 10 to 18 wt % ofsucrose, 0.01 to 0.3 wt % simethicone emulsion (30% emulsion) and 0.3 to10% NaCl, based on the total weight of the solid content of thesuspension, are sprayed (bottom spray) onto the beads through 1.2 mmnozzles at 10 mL/min and 1.5 bar of pressure until a layering of 400 to700% wt % is achieved as compared to initial beads weight. The resultingspray layered the active agent(s) of the present invention particles orthe active agent(s) of the present invention complex particles compriseabout 30 to 70 wt % of the active agent(s) of the present inventionbased on the total weight of the particles. In one embodiment thecapsule is a size 0 soft gelatin capsule In one embodiment, the capsuleis a swelling plug device. In another embodiment, the swelling plugdevice is further coated with cellulose acetate phthalate or copolymersof methacrylic acid and methylmethacrylate.

In some embodiments the capsule includes at least 250 mg (or at least300 mg or at least 400 mg) the active agent(s) of the present inventionand has a total weight of less than 800 mg (or less than 700 mg). Thecapsule may contain a plurality of the active agent(s) of the presentinvention-containing beads, for example spray layered beads. In someembodiments the beads are 12-25% the active agent(s) of the presentinvention by weight. In some embodiments some or all of the activeagent(s) of the present invention containing beads are coated with acoating comprising 6 to 15% (or 8 to 12%) of the total bead weight.Optimization work typically involves lower loading levels and the beadsconstitute 30 to 60% of the finished bead weight. The capsule maycontain a granulated composition, wherein the granulated compositioncomprises the active agent(s) of the present invention.

The capsule may be pulsatile release the active agent(s) of the presentinvention oral dosage form, comprising: (a) a first dosage unitcomprising a first the active agent(s) of the present invention dosethat is released substantially immediately following oral administrationof the dosage form to a patient; (b) a second dosage unit comprising asecond the active agent(s) of the present invention dose that isreleased approximately 3 to 7 hours following administration of thedosage form to a patient. For pulsatile release capsules containingbeads the beads can be coated with a coating comprising 6 to 15% (or 8to 12%) of the total bead weight. In some embodiments the coating is acoating that is insoluble at pH 1 to 2 and soluble at pH greater than5.5.

In certain embodiments, the formulation may comprise a pulsatile releasecapsule comprising at least two active agents. This pulsatile releasecapsule may contain a plurality of beads in which some beads areimmediate release beads and other beads are formulated, for example withthe use of a coating, for modified release, typically from about 3 toabout 10 hours after administration. In other embodiments the pulsatilerelease capsule contains a plurality of beads formulated for modifiedrelease and the active agent(s) of the present invention powder, forexample spray granulated the active agent(s) of the present invention,for immediate release.

In some embodiments, the release of the active agent(s) of the presentinvention particles can be modified with a modified release coating,such as an enteric coating using cellulose acetate phthalate or asustained release coating comprising copolymers of methacrylic acid andmethylmethacrylate. In one embodiment, the enteric coating may bepresent in an amount of about 0.5 to about 15 wt %, more specifically,about 8 to about 12 wt %, based on the weight of, e.g., the spraylayered particles. In one embodiment, the spray layered particles coatedwith the delayed and/or sustained release coatings can be filled in amodified release capsule in which both enteric coated and immediaterelease the active agent(s) of the present invention beads are filledinto a soft gelatin capsule. Additional suitable excipients may also befilled with the coated particles in the capsule. The uncoated particlesrelease the active agent(s) of the present invention immediately uponadministration while the coated particles do not release the activeagent(s) of the present invention until these particles reach intestine.By controlling the ratios of the coated and uncoated particles,desirable pulsatile release profiles may be obtained. In someembodiments, the ratios between the uncoated and the coated particlesare e.g., 20/80, or 30/70, or 40/60, or 50/50, w/w to obtain desirablerelease.

In some embodiments, the spray layered active agent(s) of the presentinvention particles can be compressed into tablets with commonly usedpharmaceutical excipients. Any appropriate apparatus for forming thecoating can be used to make the enteric coated tablets, e.g., fluidizedbed coating using a Wurster column, powder layering in coating pans orrotary coaters; dry coating by double compression technique; tabletcoating by film coating technique, and the like. See, e.g., U.S. Pat.No. 5,322,655; Remington's Pharmaceutical Sciences Handbook: Chapter 90“Coating of Pharmaceutical Dosage Forms”, 1990.

In various embodiments, the spray layered the active agent(s) of thepresent invention described above and one or more excipients are dryblended and compressed into a mass, such as a tablet, having a hardnesssufficient to provide a pharmaceutical composition that substantiallydisintegrates within less than about 30 minutes, less than about 35minutes, less than about 40 minutes, less than about 45 minutes, lessthan about 50 minutes, less than about 55 minutes, or less than about 60minutes, after oral administration, thereby releasing the activeagent(s) of the present invention formulation into the gastrointestinalfluid.

In other embodiments, the spray layered the active agent(s) of thepresent invention particles or spray layered the active agent(s) of thepresent invention complex particles with enteric coatings describedabove and one or more excipients are dry blended and compressed into amass, such as a tablet. In one embodiment, the enteric coated particlesin the tablet substantially avoids release of the active agent(s) of thepresent invention, for example less than 15 wt %, in the stomach butreleases substantially all the active agent(s) of the present invention(enterically or sustained release coated), for example, greater than 80wt %, in the intestine.

In yet other embodiments, a pulsatile release the active agent(s) of thepresent invention formulation comprises a first dosage unit comprising aformulation made from the active agent(s) of the present inventioncontaining granules made from a spray drying or spray granulatedprocedure or a formulation made from the active agent(s) of the presentinvention complex containing granules made from a spray drying or spraygranulated procedure without enteric or sustained release coatings and asecond dosage unit comprising spray layered the active agent(s) of thepresent invention particles or spray layered the active agent(s) of thepresent invention complex particles with enteric or sustained releasecoatings. In one embodiment, the first dosage unit and the second dosageunit are wet or dry blended and compressed into a mass to make apulsatile release tablet.

In another embodiment, binding, lubricating and disintegrating agentsare blended (wet or dry) to the spray layered the active agent(s) of thepresent invention to make a compressible blend. The first and the seconddosage units are compressed separately and then compressed together toform a bilayer tablet. In yet another embodiment, the first dosage unitis in the form of an overcoat and completely covers the second dosageunit.

Roller compaction, which involves dry granulation of single powder or ablended mixture of powders by the use of pressure to form dense compacts(the compacts are subsequently milled to a desired particle size),provides another alternative. It is a simple process that is readilyavailable for use, and does not involved the use of solvents forgranulation. Thus, roller compaction eliminates the exposure ofsensitive active pharmaceutical ingredients to moisture and drying.Roller compaction can also provide some enhanced stability andtaste-masking characteristics to active pharmaceutical by diluting andisolating such components in a granulated matrix of compatibleingredients. Roller compaction also imparts increased density and flowto the powder.

Extrusion/spheronization is another method that involves wet massing ofactive pharmaceutical ingredients, followed by the extrusion of the wetmass through a perforated plate to produce short cylindrical rods. Theserods are subsequently placed into a rapidly rotating spheronizer toshape the cylindrical rods into uniform spheres. The spheres aresubsequently dried using a fluid bed drier and then coated with afunctional coating using a fluid bed equipped with a Wurster insert andspray nozzle.

In other embodiments a powder comprising the active agent(s) of thepresent invention formulations described herein may be formulated tocomprise one or more pharmaceutical excipients and flavors. Such apowder may be prepared, for example, by mixing the active agent(s) ofthe present invention formulation and optional pharmaceutical excipientsto form a bulk blend composition. Additional embodiments also comprise asuspending agent and/or a wetting agent. This bulk blend is uniformlysubdivided into unit dosage packaging or multi-dosage packaging units.The term “uniform” means the homogeneity of the bulk blend issubstantially maintained during the packaging process

In still other embodiments, effervescent powders are also prepared inaccordance with the present invention. Effervescent salts have been usedto disperse medicines in water for oral administration. Effervescentsalts are granules or coarse powders containing a medicinal agent in adry mixture, usually composed of sodium bicarbonate, citric acid and/ortartaric acid. When salts of the present invention are added to water,the acids and the base react to liberate carbon dioxide gas, therebycausing “effervescence.” Examples of effervescent salts include, e.g:sodium bicarbonate or a mixture of sodium bicarbonate and sodiumcarbonate, citric acid and/or tartaric acid. Any acid-base combinationthat results in the liberation of carbon dioxide can be used in place ofthe combination of sodium bicarbonate and citric and tartaric acids, aslong as the ingredients were suitable for pharmaceutical use and resultin a pH of about 6.0 or higher.

In certain embodiments, ingredients (including or not including theactive agent(s)) of the invention are wet granulated. The individualsteps in the wet granulation process of tablet preparation includemilling and sieving of the ingredients, dry powder mixing, wet massing,granulation, drying and final grinding. In various embodiments, theactive agent(s) of the present invention composition is added to theother excipients of the pharmaceutical formulation after they have beenwet granulated.

Alternatively, the ingredients may be subjected to dry granulation,e.g., via compressing a powder mixture into a rough tablet or “slug” ona heavy-duty rotary tablet press. The slugs are then broken up intogranular particles by a grinding operation, usually by passage throughan oscillation granulator. The individual steps include mixing of thepowders, compressing (slugging) and grinding (slug reduction orgranulation). No wet binder or moisture is involved in any of the steps.In some embodiments, the active agent(s) of the present inventionformulation is dry granulated with other excipients in thepharmaceutical formulation. In other embodiments, the active agent(s) ofthe present invention formulation is added to other excipients of thepharmaceutical formulation after they have been dry granulated.

In other embodiments, the formulation of the present inventionformulations described herein is a solid dispersion. Methods ofproducing such solid dispersions are known in the art and include, butare not limited to, for example, U.S. Pat. Nos. 4,343,789, 5,340,591,5,456,923, 5,700,485, 5,723,269, and U.S. Pub. Appl. 2004/0013734, eachof which is specifically incorporated by reference. In some embodiments,the solid dispersions of the invention comprise both amorphous andnon-amorphous the active agent(s) of the present invention and can haveenhanced bioavailability as compared to conventional the active agent(s)of the present invention formulations. In still other embodiments, theactive agent(s) of the present invention formulations described hereinare solid solutions. Solid solutions incorporate a substance togetherwith the active agent and other excipients such that heating the mixtureresults in dissolution of the drug and the resulting composition is thencooled to provide a solid blend which can be further formulated ordirectly added to a capsule or compressed into a tablet. Methods ofproducing such solid solutions are known in the art and include, but arenot limited to, for example, U.S. Pat. Nos. 4,151,273, 5,281,420, and6,083,518, each of which is specifically incorporated by reference.

The pharmaceutical solid oral dosage forms comprising the activeagent(s) of the present invention described herein can be furtherformulated to provide a modified or controlled release of the activeagent(s) of the present invention. In some embodiments, the solid dosageforms described herein can be formulated as a delay release dosage formsuch as and enteric coated delayed release oral dosage forms, i.e., asan oral dosage form of a pharmaceutical composition as described hereinwhich utilizes an enteric coating to affect release in the smallintestine of the gastrointestinal tract. The enteric coated dosage formmay be a compressed or molded or extruded tablet/mold (coated oruncoated) containing granules, powder, pellets, beads or particles ofthe active ingredient and/or other composition components, which arethemselves coated or uncoated. The enteric coated oral dosage form mayalso be a capsule (coated or uncoated) containing pellets, beads orgranules of the solid carrier or the composition, which are themselvescoated or uncoated. Enteric coatings may also be used to prepare othercontrolled release dosage forms including extended release and pulsatilerelease dosage forms.

In other embodiments, the active agent(s) of the formulations describedherein are delivered using a pulsatile dosage form. Pulsatile dosageforms comprising the active agent(s) of the present inventionformulations described herein may be administered using a variety offormulations known in the art. For example, such formulations include,but are not limited to, those described in U.S. Pat. Nos. 5,011,692,5,017,381, 5,229,135, and 5,840,329, each of which is specificallyincorporated by reference. Other dosage forms suitable for use with theactive agent(s) of the present invention formulations are described in,for example, U.S. Pat. Nos. 4,871,549, 5,260,068, 5,260,069, 5,508,040,5,567,441 and 5,837,284, all of which are specifically incorporated byreference. In one embodiment, the controlled release dosage form ispulsatile release solid oral dosage form comprising at least two groupsof particles, each containing active agent(s) of the present inventionas described herein. The first group of particles provides asubstantially immediate dose of the active agent(s) of the presentinvention upon ingestion by a subject. The first group of particles canbe either uncoated or comprise a coating and/or sealant. The secondgroup of particles comprises coated particles, which comprise from about2% to about 75%, preferably from about 2.5% to about 70%, and morepreferably from about 40% to about 70%, by weight of the total dose ofthe active agent(s) of the present invention in said formulation, inadmixture with one or more binders. The coating comprises apharmaceutically acceptable ingredient in an amount sufficient toprovide a delay of from about 2 hours to about 7 hours followingingestion before release of the second dose. Suitable coatings includeone or more differentially degradable coatings such as, by way ofexample only, pH sensitive coatings (enteric coatings) such as acrylicresins (e.g., Eudragit® EPO, Eudragit® L30D-55, Eudragit® FS 30DEudragit® L100-55, Eudragit® L100, Eudragit® S100, Eudragit® RD100,Eudragit® E100, Eudragit® L12.5, Eudragit® S12.5, and Eudragit® NE30D,Eudragit® NE 40D®) either alone or blended with cellulose derivatives,e.g., ethylcellulose, or non-enteric coatings having variable thicknessto provide differential release of the active agent(s) of the presentinvention formulation.

Many other types of controlled release systems known to those ofordinary skill in the art and are suitable for use with the activeagent(s) of the present invention formulations described herein.Examples of such delivery systems include, e.g., polymer-based systems,such as polylactic and polyglycolic acid, polyanhydrides andpolycaprolactone, cellulose derivatives (e.g., ethyl cellulose), porousmatrices, nonpolymer-based systems that are lipids, including sterols,such as cholesterol, cholesterol esters and fatty acids, or neutralfats, such as mono-, di- and triglycerides; hydrogel release systems;silastic systems; peptide-based systems; wax coatings, bioerodibledosage forms, compressed tablets using conventional binders and thelike. See, e.g., Liberman et al., Pharmaceutical Dosage Forms, 2 Ed.,Vol. 1, pp. 209-214 (1990); Singh et al., Encyclopedia of PharmaceuticalTechnology, 2nd Ed., pp. 751-753 (2002); U.S. Pat. Nos. 4,327,725,4,624,848, 4,968,509, 5,461,140, 5,456,923, 5,516,527, 5,622,721,5,686,105, 5,700,410, 5,977,175, 6,465,014 and 6,932,983, each of whichis specifically incorporated by reference. In some embodiments,materials include shellac, acrylic polymers, cellulosic derivatives,polyvinyl acetate phthalate, and mixtures thereof. In other embodiments,materials include Eudragit® series E, L, RL, RS, NE, L, L300, S, 100-55,cellulose acetate phthalate, Aquateric, cellulose acetate trimellitate,ethyl cellulose, hydroxypropylmethylcellulose phthalate,hydroxypropylmethylcellulose acetate succinate, polyvinyl acetatephthalate, and Cotteric.

The controlled release systems may utilize a hydrophilic polymer,including but not limited to a water swellable polymer (e.g., a naturalor synthetic gum). The hydrophilic polymer may be any pharmaceuticallyacceptable polymer which swells and expands in the presence of water toslowly release the active agent(s) of the present invention. Thesepolymers include polyethylene oxide, methylcellulose,hydroxypropylcellulose, hydroxypropylmethylcellulose and the like. In apreferred embodiment, the water swellable polymer will be polyethyleneoxide (obtained from Union Carbide Corporation under the trade namePolyox WSR Coagulant or Polyox WSR N 80). These materials form a viscousgel in water or other solvent system at a sufficient concentration tocontrol the release of the active agent(s) of the present invention.This will generally require a concentration of the pharmaceuticallyacceptable, water swellable polymer of about 0-50% by weight of thecompressed, uncoated tablet.

The performance of acrylic polymers (primarily their solubility inbiological fluids) can vary based on the degree and type ofsubstitution. Examples of suitable acrylic polymers include methacrylicacid copolymers and ammonia methacrylate copolymers. The Eudragit seriesE, L, S, RL, RS and NE (Rohm Pharma) are available as solubilized inorganic solvent, aqueous dispersion, or dry powders. The Eudragit seriesRL, NE, and RS are insoluble in the gastrointestinal tract but arepermeable and are used primarily for colonic targeting. The Eudragitseries E dissolve in the stomach. The Eudragit series L, L-30D and S areinsoluble in stomach and dissolve in the intestine; Opadry Enteric arealso insoluble in stomach and dissolve in the intestine.

Examples of suitable cellulose derivatives are: ethyl cellulose;reaction mixtures of partial acetate esters of cellulose with phthalicanhydride. The performance can vary based on the degree and type ofsubstitution. Cellulose acetate phthalate (CAP) dissolves in pH >6.Aquateric (FMC) is an aqueous based system and is a spray dried CAPpsuedolatex with particles <1 μm. Other components in Aquateric caninclude pluronics, Tweens, and acetylated monoglycerides. Other suitablecellulose derivatives include: cellulose acetate trimellitate (Eastman);methylcellulose (Pharmacoat, Methocel); hydroxypropylmethyl cellulosephthalate (HPMCP); hydroxypropylmethyl cellulose succinate (HPMCS); andhydroxypropylmethylcellulose acetate succinate (e.g., AQOAT (ShinEtsu)). The performance can vary based on the degree and type ofsubstitution. For example, HPMCP such as, HP-50, HP-55, HP-55S, HP-55Fgrades are suitable. The performance can vary based on the degree andtype of substitution. For example, suitable grades ofhydroxypropylmethylcellulose acetate succinate include, but are notlimited to, AS-LG (LF), which dissolves at pH 5, AS-MG (MF), whichdissolves at pH 5.5, and AS-HG (HF), which dissolves at higher pH. Thesepolymers are offered as granules, or as fine powders for aqueousdispersions.

In some embodiments, the coating can, and usually does, contain aplasticizer and possibly other coating excipients such as colorants,talc, and/or magnesium stearate, which are well known in the art.Suitable plasticizers include triethyl citrate (Citroflex 2), triacetin(glyceryl triacetate), acetyl triethyl citrate (Citroflec A2), Carbowax400 (polyethylene glycol 400), diethyl phthalate, tributyl citrate,acetylated monoglycerides, glycerol, fatty acid esters, propyleneglycol, and dibutyl phthalate. In particular, anionic carboxylic acrylicpolymers usually will contain 10-25% by weight of a plasticizer,especially dibutyl phthalate, polyethylene glycol, triethyl citrate andtriacetin. Conventional coating techniques such as spray or pan coatingare employed to apply coatings. The coating thickness must be sufficientto ensure that the oral dosage form remains intact until the desiredsite of topical delivery in the intestinal tract is reached.

In some embodiments, formulations are provided comprising the activeagent(s) of the present invention particles described herein and atleast one dispersing agent or suspending agent for oral administrationto a subject. The formulation may be a powder and/or granules forsuspension, and upon admixture with water, a substantially uniformsuspension is obtained. As described herein, the aqueous dispersion cancomprise amorphous and non-amorphous the active agent(s) of the presentinvention particles of consisting of multiple effective particle sizessuch that the active agent(s) of the present invention particles havinga smaller effective particle size are absorbed more quickly and theactive agent(s) of the present invention particles having a largereffective particle size are absorbed more slowly. In certain embodimentsthe aqueous dispersion or suspension is an immediate releaseformulation. In another embodiment, an aqueous dispersion comprisingamorphous the active agent(s) of the present invention particles isformulated such that a portion of the active agent(s) of the presentinvention particles are absorbed within, e.g., about 3 hours afteradministration and about 90% of the active agent(s) of the presentinvention particles are absorbed within, e.g., about 10 hours afteradministration. In other embodiments, addition of a complexing agent tothe aqueous dispersion results in a larger span of the active agent(s)of the present invention containing particles to extend the drugabsorption phase such that 50-80% of the particles are absorbed in thefirst 3 hours and about 90% are absorbed by about 10 hours. Dosage formsfor oral administration can be aqueous suspensions selected from thegroup including, but not limited to, pharmaceutically acceptable aqueousoral dispersions, emulsions, solutions, and syrups. See, e.g., Singh etal., Encyclopedia of Pharmaceutical Technology, 2nd Ed., pp. 754-757(2002). In addition to the active agent(s) of the present inventionparticles, the liquid dosage forms may comprise additives, such as: (a)disintegrating agents; (b) dispersing agents; (c) wetting agents; (d) atleast one preservative, (e) viscosity enhancing agents, (f) at least onesweetening agent, and (g) at least one flavoring agent.

Examples of disintegrating agents for use in the aqueous suspensions anddispersions include, but are not limited to, a starch, e.g., a naturalstarch such as corn starch or potato starch, a pregelatinized starchsuch as National 1551 or Amijel®, or sodium starch glycolate such asPromogel® or Explotab®; a cellulose such as a wood product,microcrystalline cellulose, e.g., Avicel®, Avicel® PH101, Avicel® PH102,Avicel® PH105, Elcema® P100, Emcocel®, Vivacel®, Ming Tia®, andSolka-Floc®, methylcellulose, croscarmellose, or a cross-linkedcellulose, such as cross-linked sodium carboxymethylcellulose(Ac-Di-Sol®), cross-linked carboxymethylcellulose, or cross-linkedcroscarmellose; a cross-linked starch such as sodium starch glycolate; across-linked polymer such as crosspovidone; a cross-linkedpolyvinylpyrrolidone; alginate such as alginic acid or a salt of alginicacid such as sodium alginate; a clay such as Veegum® HV (magnesiumaluminum silicate); a gum such as agar, guar, locust bean, Karaya,pectin, or tragacanth; sodium starch glycolate; bentonite; a naturalsponge; a surfactant; a resin such as a cation-exchange resin; citruspulp; sodium lauryl sulfate; sodium lauryl sulfate in combinationstarch; and the like.

In some embodiments, the dispersing agents suitable for the aqueoussuspensions and dispersions described herein are known in the art andinclude, for example, hydrophilic polymers, electrolytes, Tween® 60 or80, PEG, polyvinylpyrrolidone (PVP; commercially known as Plasdone®),and the carbohydrate-based dispersing agents such as, for example,hydroxypropylcellulose and hydroxypropylcellulose ethers (e.g., HPC,HPC-SL, and HPC-L), hydroxypropylmethylcellulose andhydroxypropylmethylcellulose ethers (e.g. HPMC K100, HPMC K4M, HPMCK15M, and HPMC K100M), carboxymethylcellulose sodium, methylcellulose,hydroxyethylcellulose, hydroxypropylmethylcellulose phthalate,hydroxypropylmethylcellulose acetate stearate, noncrystalline cellulose,magnesium aluminum silicate, triethanolamine, polyvinyl alcohol (PVA),polyvinylpyrrolidone/vinyl acetate copolymer (Plasdone®, e.g., S-630),4-(1,1,3,3-tetramethylbutyl)-phenol polymer with ethylene oxide andformaldehyde (also known as tyloxapol), poloxamers (e.g., PluronicsF68®, F88®, and F108®, which are block copolymers of ethylene oxide andpropylene oxide); and poloxamines (e.g., Tetronic 908®, also known asPoloxamine 908®, which is a tetrafunctional block copolymer derived fromsequential addition of propylene oxide and ethylene oxide toethylenediamine (BASF Corporation, Parsippany, N.J.)). In otherembodiments, the dispersing agent is selected from a group notcomprising one of the following agents: hydrophilic polymers;electrolytes; Tween® 60 or 80; PEG; polyvinylpyrrolidone (PVP);hydroxypropylcellulose and hydroxypropyl cellulose ethers (e.g., HPC,HPC-SL, and HPC-L); hydroxypropyl methylcellulose and hydroxypropylmethylcellulose ethers (e.g. HPMC K100, HPMC K4M, HPMC K15M, HPMC K100M,and Pharmacoat® USP 2910 (Shin-Etsu)); carboxymethylcellulose sodium;methylcellulose; hydroxyethylcellulose; hydroxypropylmethyl-cellulosephthalate; hydroxypropylmethyl-cellulose acetate stearate;non-crystalline cellulose; magnesium aluminum silicate; triethanolamine;polyvinyl alcohol (PVA); 4-(1,1,3,3-tetramethylbutyl)-phenol polymerwith ethylene oxide and formaldehyde; poloxamers (e.g., Pluronics F68®,F88®, and F108®, which are block copolymers of ethylene oxide andpropylene oxide); or poloxamines (e.g., Tetronic 908®, also known asPoloxamine 908®).

Wetting agents (including surfactants) suitable for the aqueoussuspensions and dispersions described herein are known in the art andinclude, but are not limited to, acetyl alcohol, glycerol monostearate,polyoxyethylene sorbitan fatty acid esters (e.g., the commerciallyavailable Tweens® such as e.g., Tween 20® and Tween 80® (ICI SpecialtyChemicals)), and polyethylene glycols (e.g., Carbowaxs 3350® and 1450®,and Carpool 934® (Union Carbide)), oleic acid, glyceryl monostearate,sorbitan monooleate, sorbitan monolaurate, triethanolamine oleate,polyoxyethylene sorbitan monooleate, polyoxyethylene sorbitanmonolaurate, sodium oleate, sodium lauryl sulfate, sodium docusate,triacetin, vitamin E TPGS, sodium taurocholate, simethicone,phosphotidylcholine and the like.

Suitable preservatives for the aqueous suspensions or dispersionsdescribed herein include, for example, potassium sorbate, parabens(e.g., methylparaben and propylparaben) and their salts, benzoic acidand its salts, other esters of parahydroxybenzoic acid such asbutylparaben, alcohols such as ethyl alcohol or benzyl alcohol, phenoliccompounds such as phenol, or quaternary compounds such as benzalkoniumchloride. Preservatives, as used herein, are incorporated into thedosage form at a concentration sufficient to inhibit microbial growth.In one embodiment, the aqueous liquid dispersion can comprisemethylparaben and propylparaben in a concentration ranging from about0.01% to about 0.3% methylparaben by weight to the weight of the aqueousdispersion and about 0.005% to about 0.03% propylparaben by weight tothe total aqueous dispersion weight. In yet another embodiment, theaqueous liquid dispersion can comprise methylparaben from about 0.05 toabout 0.1 weight % and propylparaben from about 0.01 to about 0.02weight % of the aqueous dispersion.

Suitable viscosity enhancing agents for the aqueous suspensions ordispersions described herein include, but are not limited to, methylcellulose, xanthan gum, carboxymethylcellulose, hydroxypropyl cellulose,hydroxypropylmethyl cellulose, Plasdone® S-630, carbomer, polyvinylalcohol, alginates, acacia, chitosans and combinations thereof. Theconcentration of the viscosity enhancing agent will depend upon theagent selected and the viscosity desired.

Examples of natural and artificial sweetening agents suitable for theaqueous suspensions or dispersions described herein include, forexample, acacia syrup, acesulfame K, alitame, anise, apple, aspartame,banana, Bavarian cream, berry, black currant, butterscotch, calciumcitrate, camphor, caramel, cherry, cherry cream, chocolate, cinnamon,bubble gum, citrus, citrus punch, citrus cream, cotton candy, cocoa,cola, cool cherry, cool citrus, cyclamate, cylamate, dextrose,eucalyptus, eugenol, fructose, fruit punch, ginger, glycyrrhetinate,glycyrrhiza (licorice) syrup, grape, grapefruit, honey, isomalt, lemon,lime, lemon cream, monoammonium glyrrhizinate (MagnaSweet®), maltol,mannitol, maple, marshmallow, menthol, mint cream, mixed berry,neohesperidine DC, neotame, orange, pear, peach, peppermint, peppermintcream, Prosweet® Powder, raspberry, root beer, rum, saccharin, safrole,sorbitol, spearmint, spearmint cream, strawberry, strawberry cream,stevia, sucralose, sucrose, sodium saccharin, saccharin, aspartame,acesulfame potassium, mannitol, talin, sucralose, sorbitol, Swiss cream,tagatose, tangerine, thaumatin, tutti fruitti, vanilla, walnut,watermelon, wild cherry, wintergreen, xylitol, or any combination ofthese flavoring ingredients, e.g., anise-menthol, cherry-anise,cinnamon-orange, cherry-cinnamon, chocolate-mint, honey-lemon,lemon-lime, lemon-mint, menthol-eucalyptus, orange-cream, vanilla-mint,and mixtures thereof. In one embodiment, the aqueous liquid dispersioncan comprise a sweetening agent or flavoring agent in a concentrationranging from about 0.0001% to about 10.0% the weight of the aqueousdispersion. In another embodiment, the aqueous liquid dispersion cancomprise a sweetening agent or flavoring agent in a concentrationranging from about 0.0005% to about 5.0% wt % of the aqueous dispersion.In yet another embodiment, the aqueous liquid dispersion can comprise asweetening agent or flavoring agent in a concentration ranging fromabout 0.0001% to 0.1 wt %, from about 0.001% to about 0.01 weight %, orfrom 0.0005% to 0.004% of the aqueous dispersion.

In addition to the additives listed above, the liquid the activeagent(s) of the present invention formulations can also comprise inertdiluents commonly used in the art, such as water or other solvents,solubilizing agents, and emulsifiers.

In some embodiments, formulations described herein can beself-emulsifying drug delivery systems (SEDDS). Emulsions aredispersions of one immiscible phase in another, usually in the form ofdroplets. Generally, emulsions are created by vigorous mechanicaldispersion. SEDDS, as opposed to emulsions or microemulsions,spontaneously form emulsions when added to an excess of water withoutany external mechanical dispersion or agitation. An advantage of SEDDSis that only gentle mixing is required to distribute the dropletsthroughout the solution. Additionally, water or the aqueous phase can beadded just prior to administration, which ensures stability of anunstable or hydrophobic active ingredient. Thus, the SEDDS provides aneffective delivery system for oral and parenteral delivery ofhydrophobic active ingredients. SEDDS may provide improvements in thebioavailability of hydrophobic active ingredients. Methods of producingself-emulsifying dosage forms are known in the art include, but are notlimited to, for example, U.S. Pat. Nos. 5,858,401, 6,667,048, and6,960,563, each of which is specifically incorporated by reference.Exemplary emulsifiers are ethyl alcohol, isopropyl alcohol, ethylcarbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propyleneglycol, 1,3-butyleneglycol, dimethylformamide, sodium lauryl sulfate,sodium doccusate, cholesterol, cholesterol esters, taurocholic acid,phosphotidylcholine, oils, such as cottonseed oil, groundnut oil, corngerm oil, olive oil, castor oil, and sesame oil, glycerol,tetrahydrofurfuryl alcohol, polyethylene glycols, fatty acid esters ofsorbitan, or mixtures of these substances, and the like.

In certain embodiments, the active agent(s) may be administered viaIntranasal formulations which are known in the art and are described in,for example, U.S. Pat. Nos. 4,476,116, 5,116,817 and 6,391,452, each ofwhich is specifically incorporated by reference. The active agent(s) ofthe present invention prepared according to these and other techniqueswell-known in the art are prepared as solutions in saline, employingbenzyl alcohol or other suitable preservatives, fluorocarbons, and/orother solubilizing or dispersing agents known in the art. See, forexample, Ansel, H. C. et al., Pharmaceutical Dosage Forms and DrugDelivery Systems, Sixth Ed. (1995). Preferably these compositions andformulations are prepared with suitable nontoxic pharmaceuticallyacceptable ingredients. These ingredients are known to those skilled inthe preparation of nasal dosage forms and some of these can be found inREMINGTON: THE SCIENCE AND PRACTICE OF PHARMACY, 21st edition, 2005, astandard reference in the field. The choice of suitable carriers ishighly dependent upon the exact nature of the nasal dosage form desired,e.g., solutions, suspensions, ointments, or gels. Nasal dosage formsgenerally contain large amounts of water in addition to the activeingredient. Minor amounts of other ingredients such as pH adjusters,emulsifiers or dispersing agents, preservatives, surfactants, gellingagents, complexing agents or buffering and other stabilizing andsolubilizing agents may also be present. Preferably, the nasal dosageform should be isotonic with nasal secretions.

In certain embodiments, the active agent(s) may be administered viabuccal formulations such as, but are not limited to, U.S. Pat. Nos.4,229,447, 4,596,795, 4,755,386, and 5,739,136, each of which isspecifically incorporated by reference. In addition, the buccal dosageforms described herein can further comprise a bioerodible (hydrolyzable)polymeric carrier that may also serves to adhere the dosage form to thebuccal mucosa. The buccal dosage form is fabricated so as to erodegradually over a predetermined time period, wherein the active agent(s)of the present invention delivery is provided essentially throughout.Buccal drug delivery, as will be appreciated by those skilled in theart, avoids the disadvantages encountered with oral drug administration,e.g., slow drug absorption, degradation of the active agent by fluidspresent in the gastrointestinal tract and/or first-pass inactivation inthe liver. With regard to the bioerodible (hydrolysable) polymericcarrier, it will be appreciated that virtually any such carrier can beused, so long as the desired drug release profile is not comprised, andthe carrier is compatible with the active agent(s) of the presentinvention and any other components that may be present in the buccaldosage unit. Generally, the polymeric carrier comprises hydrophilic(water-soluble and water-swellable) polymers that adhere to the wetsurface of the buccal mucosa. Examples of polymeric carriers usefulherein include acrylic acid polymers and co, e.g., those known as“carbomers” (Carbopol®, which may be obtained from B.F. Goodrich, is onesuch polymer). Other components may also be incorporated into the buccaldosage forms described herein include, but are not limited to,disintegrants, diluents, binders, lubricants, flavoring, colorants,preservatives, and the like.

In certain embodiments, the active agent(s) may be administered viatransdermal formulations using a variety of devices which have beendescribed in the art. For example, such devices include, but are notlimited to, U.S. Pat. Nos. 3,598,122, 3,598,123, 3,710,795, 3,731,683,3,742,951, 3,814,097, 3,921,636, 3,972,995, 3,993,072, 3,993,073,3,996,934, 4,031,894, 4,060,084, 4,069,307, 4,077,407, 4,201,211,4,230,105, 4,292,299, 4,292,303, 5,336,168, 5,665,378, 5,837,280,5,869,090, 6,923,983, 6,929,801 and 6,946,144, each of which isspecifically incorporated by reference in its entirety. In someembodiments, the transdermal delivery device used with the activeagent(s) of the present invention described herein can comprise a powersource, radio frequency, or a brief electrical current tomicro-electrodes in the skin creating “channels” or “pores” in thestratum corneum to facilitate the delivery of the active agent(s) of thepresent invention formulation, such methods are known in the art and aredescribed in, for example U.S. Pat. Nos. 6,611,706, 6,708,060, and6,711,435, each of which is specifically incorporated by reference inits entirety. In other embodiments, the transdermal delivery device cancomprise a means for porating the stratum corneum, e.g., micro-lancing,application of sonic energy, or hydraulic puncturing, to facilitate thedelivery of the active agent(s) of the present invention, such methodsare known in the art and are described in, for example, U.S. Pat. Nos.6,142,939 and 6,527,716, each of which is specifically incorporated byreference in its entirety. The pores described by the methods herein aretypically about 20-50 microns in depth and to not extend into areas ofinnervation or vascularization.

The transdermal dosage forms described herein may incorporate certainpharmaceutically acceptable excipients which are conventional in theart. In general, the transdermal formulations described herein compriseat least three components: (1) the active agent(s) of the presentinvention; (2) a penetration enhancer; and (3) an aqueous adjuvant. Inaddition, transdermal formulations can include additional componentssuch as, but not limited to, gelling agents, creams and ointment bases,and the like. In some embodiments, the transdermal formulation canfurther comprise a woven or non-woven backing material to enhance drugabsorption and prevent the removal of the transdermal formulation fromthe skin. In other embodiments, the transdermal formulations describedherein can maintain a saturated or supersaturated state to promotediffusion into the skin.

The active agent(s) of the present invention formulations suitable forintramuscular, subcutaneous, or intravenous injection may comprisephysiologically acceptable sterile aqueous or non-aqueous solutions,dispersions, suspensions or emulsions, and sterile powders forreconstitution into sterile injectable solutions or dispersions.Examples of suitable aqueous and non-aqueous carriers, diluents,solvents, or vehicles including water, ethanol, polyols (propyleneglycol, polyethylene-glycol, glycerol, cremophor and the like), suitablemixtures thereof, vegetable oils (such as olive oil) and injectableorganic esters such as ethyl oleate. Additionally, the active agent(s)of the present invention can be dissolved at concentrations of >1 mg/mlusing water soluble beta cyclodextrins (e.g.beta-sulfobutyl-cyclodextrin and 2-hydroxypropylbetacyclodextrin. Properfluidity can be maintained, for example, by the use of a coating such aslecithin, by the maintenance of the required particle size in the caseof dispersions, and by the use of surfactants. The active agent(s) ofthe present invention formulations suitable for subcutaneous injectionmay also contain additives such as preserving, wetting, emulsifying, anddispensing agents. Prevention of the growth of microorganisms can beensured by various antibacterial and antifungal agents, such asparabens, benzoic acid, benzyl alcohol, chlorobutanol, phenol, sorbicacid, and the like. It may also be desirable to include isotonic agents,such as sugars, sodium chloride, and the like. Prolonged drug absorptionof the injectable pharmaceutical form can be brought about by the use ofagents delaying absorption, such as aluminum monostearate and gelatin.The active agent(s) of the present invention suspension formulationsdesigned for extended release via subcutaneous or intramuscularinjection can avoid first pass metabolism and lower dosages of theactive agent(s) of the present invention will be necessary to maintainplasma levels of about 50 ng/ml. In such formulations, the particle sizeof the active agent(s) of the present invention particles and the rangeof the particle sizes of the active agent(s) of the present inventionparticles can be used to control the release of the drug by controllingthe rate of dissolution in fat or muscle.

The particular choice of active agents used will depend upon thediagnosis of the attending physicians and their judgment of thecondition of the patient and the appropriate treatment protocol. Each ofthe active agents may be administered concurrently (e.g.,simultaneously, essentially simultaneously or within the same treatmentprotocol) or sequentially, depending upon the nature of theproliferative disease, the condition of the patient, and the actualchoice of compounds used. The determination of the order ofadministration, and the number of repetitions of administration of eachactive agent during a treatment protocol, is well within the knowledgeof the skilled physician after evaluation of the disease being treatedand the condition of the patient.

It is understood that the dosage regimen to treat, prevent, orameliorate the condition(s) for which relief is sought, can be modifiedin accordance with a variety of factors. These factors include thedisorder from which the subject suffers, as well as the age, weight,sex, diet, and medical condition of the subject. Thus, the dosageregimen actually employed can vary widely and therefore can deviate fromthe dosage regimens set forth herein.

The pharmaceutical agents which make up the combination therapydisclosed herein may be a combined dosage form or in separate dosageforms intended for substantially simultaneous administration. Thepharmaceutical agents that make up the combination therapy may also beadministered sequentially, with either therapeutic compound beingadministered by a regimen calling for two-step administration. Thetwo-step administration regimen may call for sequential administrationof the active agents or spaced-apart administration of the separateactive agents. The time period between the multiple administration stepsmay range from, a few minutes to several hours, depending upon theproperties of each pharmaceutical agent, such as potency, solubility,bioavailability, plasma half-life and kinetic profile of thepharmaceutical agent. Circadian variation of the target moleculeconcentration may also determine the optimal dose interval.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

A unique combination of entry criteria for metabolic syndrome patientsbased on the guidelines recommended by the American Association ofClinical Endocrinologists will be used to select patients which wouldinclude moderate risk (MR) as well as high risk (HR) which wouldinclude: A1c> or =6.5, BMI> or =27 Kg/m2 (MR), BMI>=40 Kg/m2 (HR),Fasting plasma glucose (FPG)> or =126 mg/dL, 2 hour GTT (Glucosetolerance test)> or =200 mg/dL, non-fasting laboratory glucose> or =200mg/dL, LDL-C> or =100 mg/dL, TG> or =150 mg/dL, non HDL-C> or =130mg/dL, HDL-C< or =40 mg/dL, TC/HDL-C> or =3.5, ApoB> or =90 mg/dL, B.P.(blood pressure)> or =130/80 mm Hg. Other symptoms such as polydipsia,polyurea and/or polyphagia will also be considered.

In addition to the entry criteria, a set of risk stratification criteriawill be used which would include or exclude patients which may contain:lack of adequate therapeutic and overall clinical benefit frompreviously prescribed mono- and combination therapies, BMI (BMI> or =27Kg/m2), Age (> or =45 yrs), elevated B.P. (> or =130/80 mm Hg),abdominal adiposity (prototypical and/or pear-shaped), cigarettesmoking, hsCRP> or =2.0, excessive alcohol intake, family history ofType II diabetes, family history of coronary heart disease (CHD),pancreatis or hepatitis, chronic kidney disease or pre-existing renalimpairment (Creatinine level> or =1.5 mg/dL in males and > or =1.4 mg/dLin females; eGFR (estimated glomerular filtration rate)< or =60ml/min/1.73 m2), recent change in body weight (> or =5%), abnormal livertest (ALT> or =40), previous use of ACE inhibitors or ARBs etc.

All drug combinations will be titrated individually and in combinationsfor efficacy and safety in appropriate Type II diabetes and metabolicsyndrome pre-clinical in vivo models. Final doses of drugs, FDCcombinations and number of administrations daily depends on thepatient's response and tolerance. The optimal dosage, FDC combination ofdrugs and modified release kinetics will be determined based on theoverall desired clinical effect with minimal adverse side effects. Doseswill be reduced or adjusted for patients' risk stratification criteriae.g. renal impairment.

The following examples illustrate various aspects of the presentinvention. They are not to be construed to limit the claims in anymanner whatsoever.

Example 1—Anti-Inflammatory-Centric FDC Formulations (Type II DiabetesDrugs): Two Drug Combinations (IR & IR)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as Sulfonyl ureas such as 125 mgto 500 mg Chloropropamide or 125 mg to 500 mg Tolbutamide or 50 to 250mg Tolazamide or 1.25 mg to 0.5 mg to 15 mg Glipizide or 0.5 mg to 20 mgGlyburide or 0.5 mg to 8 mg Glimepiride; or Biguanides such as 250 mg to2000 mg Metformin; or Thiozolidinediones (TZDs) such as 7.5 mg to 30 mgPioglitazone or 2 mg to 8 mg Rosiglitazone; or alpha glucosidaseinhibitors such as 25 mg to 100 mg Acarbose or 12.5 mg 100 mg Miglitol;or DPPIV inhibitors such as 12.5 mg to 100 mg Sitagliptin, 3 mg to 25 mgAlogliptin or 2.5 mg Linagliptin; or SGLT-2 (Sodium Glucoseco-transporters) inhibitors such as 2.5 mg to 10 mg Dapagliflozin or 50to 300 mg Canagliflozin formulated in an IR form.

Example 2—Anti-Inflammatory-Centric FDC Formulations (Type II DiabetesDrugs): Two Drug Combinations (IR & ER)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as Sulfonyl ureas such as 500 mgChloropropamide or 500 mg Tolbutamide or 100 mg Tolazamide or 20 mgGlipizide or 10 mg Glyburide or 8 mg Glimepiride; or Biguanides such as500 mg Metformin; or Thiozolidinediones (TZDs) such as 30 mgPioglitazone or 8 mg Rosiglitazone; or alpha glucosidase inhibitors suchas 100 mg Acarbose or 100 mg Miglitol; or DPP-IV inhibitors such as 250mg Sitagliptin, 25 mg Alogliptin or 10 mg Linagliptin; or SGLT-2 (SodiumGlucose co-transporters) inhibitors such as 25 mg Dapagliflozin or 300mg Canagliflozin in an ER form.

Example 2—Anti-Inflammatory-Centric FDC Formulations (Type II DiabetesDrugs): Two Drug Combinations (IR & DR)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as Sulfonyl ureas such as 125 mgto 500 mg Chloropropamide or 125 mg to 500 mg Tolbutamide or 50 to 250mg Tolazamide or 1.25 mg to 0.5 mg to 15 mg Glipizide or 0.5 mg to 20 mgGlyburide or 0.5 mg to 8 mg Glimepiride; or Biguanides such as 250 mg to2000 mg Metformin; or Thiozolidinediones (TZDs) such as 7.5 mg to 30 mgPioglitazone or 2 mg to 8 mg Rosiglitazone; or alpha glucosidaseinhibitors such as 25 mg to 100 mg Acarbose or 12.5 mg 100 mg Miglitol;or DPPIV inhibitors such as 12.5 mg to 100 mg Sitagliptin, 3 mg to 25 mgAlogliptin or 2.5 mg Linagliptin; or SGLT-2 (Sodium Glucoseco-transporters) inhibitors such as 2.5 mg to 10 mg Dapagliflozin or 50to 300 mg Canagliflozin formulated in an IR form.

Example 3—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/SulfonylUrea/Biguanides

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as Sulfonyl ureas such as 125 mgto 500 mg Chloropropamide or 125 mg to 500 mg Tolbutamide or 50 to 250mg Tolazamide or 1.25 mg to 0.5 mg to 15 mg Glipizide or 0.5 mg to 20 mgGlyburide or 0.5 mg to 8 mg Glimepiride in an IR form and Biguanidessuch as 250 mg to 2000 mg Metformin in an ER form.

Example 4—Celecoxib/Metformin (IR/IR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an IRform.

Example 5—Celecoxib/Metformin (IR/ER)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an ERform.

Example 6—Celecoxib/Metformin (IR/ER)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an IR aswell as an ER form.

Example 7—Celecoxib/Metformin (IR/IR/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an IR aswell as DR form.

Example 8—Celecoxib/Metformin (IR/ER/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an ER aswell as DR form.

Example 9—Celecoxib/Valsartan (IR/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 40 mg to 320 mg Valsartan (an ARB) in aDR form.

Example 10—Celecoxib/Valsartan (IR/ER)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 40 mg to 320 mg Valsartan (an ARB) in anER form.

Example 11—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/DPP-IVInhibitors/Biguanides

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as 500 mg Metformin in an IR formwith DPP-IV inhibitors such as 12.5 mg to 100 mg Sitagliptin, 3 mg to 25mg Alogliptin or 2.5 mg Linagliptin in an IR form along with Biguanidessuch as 250 mg to 2000 mg Metformin in an ER form.

Example 12—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/SGLT-2Inhibitors/Biguanides

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as SGLT-2 (Sodium Glucoseco-transporters) inhibitors such as 2.5 mg to 10 mg Dapagliflozin or 50to 300 mg Canagliflozin formulated in an IR form along with Biguanidessuch as 500 mg Metformin in an ER form.

Example 13—Three Drug Combinations (IR/IR/DR): Anti-Inflammatory/DPP-IVInhibitors/SGLT-2 Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form in combinationwith anti-type II diabetes drugs such as 500 mg Metformin in an IR formwith DPPIV inhibitors such as 12.5 mg to 100 mg Sitagliptin, 3 mg to 25mg Alogliptin or 2.5 mg Linagliptin in an IR form along with SGLT-2(Sodium Glucose co-transporters) inhibitors like 5 mg Dapagliflozin or100 mg Canagliflozin in a DR form administered once or twice a day(b.i.d).

Example 14—Celecoxib/Metformin/Valsartan (IR/IR/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an IRform and 40 mg to 320 mg Valsartan (an ARB) in a DR form.

Example 15—Celecoxib/Metformin/Valsartan (IR/ER/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an ERform and 40 mg to 320 mg Valsartan (an ARB) in a DR form.

Example 16—Celecoxib/Metformin/Valsartan (IR/ER & DR/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR form in combination with 250 mg to 2000 mg of Metformin, abiguanide (anti-Type II diabetes or anti-hyperglycemic drug) in an ER aswell as a DR form and 40 mg to 320 mg Valsartan (an ARB) in a DR form.

Example 17—Biguanide/Valsartan/Celecoxib (IR/IR/DR)

250 mg to 2000 mg of Metformin, a biguanide (anti-Type II diabetes oranti-hyperglycemic drug) in an IR form and 40 mg to 320 mg Valsartan (anARB) in an IR form and 50 mg to 400 mg of Celecoxib (ananti-inflammatory drug) in a DR form.

Example 18—Metformin/Valsartan/Celecoxib (ER/IR/DR)

250 mg to 2000 mg of Metformin, a biguanide (anti-Type II diabetes oranti-hyperglycemic drug) in an ER form and 40 mg to 320 mg Valsartan (anARB) in an IR form and 50 mg to 400 mg of Celecoxib (ananti-inflammatory drug) in a DR form.

Example 19—Celecoxib/Metformin/Valsartan (IR & ER/ER/DR)

50 mg to 400 mg of Celecoxib (an anti-inflammatory drug) formulated inan IR as well as in an ER form in combination with 250 mg to 2000 mg ofMetformin, a biguanide (anti-Type II diabetes or anti-hyperglycemicdrug) in an ER as well as a DR form and 40 mg to 320 mg Valsartan (anARB) in a DR form.

Example 20—Four Drug Combinations (IR/IR/ER/DR):Anti-Inflammatory/DPP-IV Inhibitors/Biguanides/SGLT-2 Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with anti-type IIdiabetes drugs such as DPP-IV inhibitors such as 12.5 mg to 100 mgSitagliptin, 3 mg to 25 mg Alogliptin or 2.5 mg Linagliptin in an IRform in combination with Biguanides such as 500 mg Metformin in an ERform along with SGLT-2 (Sodium Glucose co-transporters) inhibitors like5 mg Dapagliflozin or 100 mg Canagliflozin in a DR form administeredonce or twice a day (b.i.d).

Example 21—Combination of 2-4 Drug Combinations with Incretin Mimetics

Two to four drug combinations described above can be combined withsub-cutaneous administration (S.C.) Incretin mimetics such as 5 ugExenatide or 0.65 mg-1.8 mg Liraglutide (Victoza).

Example 22—Combination of 2-4 Drug Combinations with TZDs (Glitazones)

Two drug combinations (IR/DR): Anti-inflammatory/glitazones; 200 mgIbuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin or Aspirin-likedrugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mg Celecoxib or 200 mgSulindac or an appropriate dose of other known anti-inflammatory drugswill be formulated in an IR form in combination with anti-Type IIdiabetes drugs such as 30 mg Pioglitazone or 8 mg Rosiglitazone in a DRform.

Three drug combinations (IR/IR/DR): Anti-inflammatory/Biguanides/TZDs(Thiozolidinediones) or glitazones; 200 mg Ibuprofen or 250 mgNaproxen-Sodium or 325 mg of Aspirin or Aspirin-like drugs (e.g.Ascriptin, Ecotrin) or 50 mg to 400 mg Celecoxib or 200 mg Sulindac oran appropriate dose of other known anti-inflammatory drugs will beformulated in an IR form in combination with anti-Type II diabetes drugssuch as 500 mg to 1000 mg Metformin in an IR form with TZDs such as 30mg Pioglitazone or 8 mg Rosiglitazone in a DR form.

Three drug combinations (IR/IR/DR): Anti-inflammatory/SGLT-2inhibitors/glitazones; 200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325mg of Aspirin or Aspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mgto 400 mg Celecoxib or 200 mg Sulindac or an appropriate dose of otherknown anti-inflammatory drugs will be formulated in an IR form incombination with anti-Type II diabetes drugs such as 25 mg Dapagliflozinor 300 mg Canagliflozin in an IR form with TZDs such as 30 mgPioglitazone or 8 mg Rosiglitazone in a DR form.

Three drug combinations (IR/IR/DR): Anti-inflammatory/DPP-IVinhibitors/glitazones; 200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325mg of Aspirin or Aspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mgto 400 mg Celecoxib or 200 mg Sulindac or an appropriate dose of otherknown anti-inflammatory drugs will be formulated in an IR form incombination with anti-Type II diabetes drugs such as 250 mg Sitagliptinor 25 mg Alogliptin or 10 mg Linagliptin in an IR form with TZDs such as30 mg Pioglitazone or 8 mg Rosiglitazone in a DR form.

Four drug combinations (IR/IR/ER/DR): Anti-inflammatory/SGLT-2inhibitors/Biguanides/Glitazones; 200 mg Ibuprofen or 250 mgNaproxen-Sodium or 325 mg of Aspirin or Aspirin-like drugs (e.g.Ascriptin, Ecotrin) or 50 mg to 400 mg Celecoxib or 200 mg Sulindac oran appropriate dose of other known anti-inflammatory drugs will beformulated in an IR form in combination with anti-Type II diabetes drugssuch as 25 mg Dapagliflozin or 300 mg Canagliflozin in an IR form with500 mg to 1000 mg Metformin in an ER form TZDs such as 30 mgPioglitazone or 8 mg Rosiglitazone in a DR form.

Four drug combinations (IR/IR/ER/DR): Anti-inflammatory/DPP-IVinhibitors/Biguanides/Glitazones; 200 mg Ibuprofen or 250 mgNaproxen-Sodium or 325 mg of Aspirin or Aspirin-like drugs (e.g.Ascriptin, Ecotrin) or 50 mg to 400 mg Celecoxib or 200 mg Sulindac oran appropriate dose of other known anti-inflammatory drugs will beformulated in an IR form in combination with anti-Type II diabetes drugssuch as 250 mg Sitagliptin or 25 mg Alogliptin or 10 mg Linagliptin inan IR form with 500 mg to 1000 mg Metformin in an ER form TZDs such as30 mg Pioglitazone or 8 mg Rosiglitazone in a DR form.

Example 23—Lipid Lowering Drugs: Two Drug Combinations (IR/IR)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Statins suchas 5 mg-80 mg Atorvastatin or 10 mg to 80 mg Fluvastatin or 5 mg to 80mg Lovastatin or 20 mg to 80 mg Provastatin or 2.5 mg to 40 mgRosuvastatin or 2.5 mg to 40 mg Simvastatin; or Nicotinic acids (Niacin)such as 250 mg to 500 mg Nicolar or 250 mg to 500 mg Niaspan; orFibrates such as 24 to 145 mg Tricor or 500 mg to 1200 mg Lopid or 2.5mg to 10 mg Ezetimide and administered once or twice daily depending onpatients response and tolerance.

Example 24—Lipid Lowering Drugs: Two Drug Combinations (IR/ER)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Statins suchas 80 mg Atorvastatin or 80 mg Provastatin or 40 mg Rosuvastatin or 40mg Simvastatin; or Niacins such as 500 mg to 2000 mg Nicolar or 500 mgto 2000 mg Niaspan; Fibrates such as 145 mg Tricor or 600 mg to 1200 mgLopid formulated in the ER form.

Example 25—Lipid Lowering Drugs: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Statins/Niacin

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Statins suchas 5 mg-80 mg Atorvastatin or 10 mg to 80 mg Fluvastatin or 5 mg to 80mg Lovastatin or 20 mg to 80 mg Provastatin or 2.5 mg to 40 mgRosuvastatin or 2.5 mg to 40 mg Simvastatin formulated in the IR formwill be combined with Nicotinic acids such as 500 mg to 2000 mg Nicolaror 500 mg to 2000 mg Niaspan formulated in the ER form.

Example 26—Lipid Lowering Drugs: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Statins/Fibrates

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Statins suchas 5 mg-80 mg Atorvastatin or 10 mg to 80 mg Fluvastatin or 5 mg to 80mg Lovastatin or 20 mg to 80 mg Provastatin or 2.5 mg to 40 mgRosuvastatin or 2.5 mg to 40 mg Simvastatin formulated in the IR formwill be combined with Fibrates such as 145 mg Tricor or 600 mg to 1200mg Lopid formulated in the ER form.

Example 27—Lipid Lowering Drugs: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Niacins/Statins

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Niacins suchas 500 mg to 2000 mg Nicolar or 500 mg to 2000 mg Niaspan formulated inthe IR form will be combined with Statins such as 80 mg Atorvastatin or80 mg Provastatin or 40 mg Rosuvastatin or 40 mg Simvastatin formulatedin the ER form.

Example 28—Lipid Lowering Drugs: Three Drug Combinations (IR/IR/DR):Anti-Inflammatory/Fibrates/Statins

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Fibrates suchas 24 to 145 mg Tricor or 500 mg to 1200 mg Lopid or 2.5 mg to 10 mgEzetimide formulated in the IR form will be combined with Statins suchas 80 mg Atorvastatin or 80 mg Provastatin or 40 mg Rosuvastatin or 40mg Simvastatin formulated in the ER form.

Example 29—Lipid Lowering Drugs: Four Drug Combinations (IR/IR/ER/DR):Anti-Inflammatory/Statins/Niacins/Fibrates

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Statins suchas 5 mg-80 mg Atorvastatin or 10 mg to 80 mg Fluvastatin or 5 mg to 80mg Lovastatin or 20 mg to 80 mg Provastatin or 2.5 mg to 40 mgRosuvastatin or 2.5 mg to 40 mg Simvastatin formulated in the IR formwith Niacins such as 500 mg to 2000 mg Nicolar or 500 mg to 2000 mgNiaspan formulated in the ER form will be combined with Fibrates such as24 to 145 mg Tricor or 500 mg to 1200 mg Lopid or 2.5 mg to 10 mgEzetimide formulated in the DR form.

Example 17—Anti-Inflammatory/Anti-Hypertensive Drugs: Two DrugCombinations (IR/IR)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone; or Beta blockers such as0.5 mg to 60 mg Timolol or 1.25 mg to 10 mg Cartelol Hydrochloride or1.5 mg to 50 mg Corredilol or 20 mg to 640 mg Propranodol or 2.5 mg to40 mg Betaxolol or 10 mg to 80 mg Penbutolol Sulfate or 50 mg to 450 mgMetoprolol or 100 mg to 1200 mg Acebutolol or 25 mg to 200 mg Atenololor 2.5 mg to 20 mg Pindolol or 50 mg to 2400 mg Labetolol; Alphablockers such as 0.5 mg to 16 mg Doxazocin or 0.5 mg to 20 mg Terazocinor 0.5 mg to 20 mg Prazocin; Angiotensin-converting enzyme (ACE)inhibitors such as 0.5 mg to 80 mg Quinapril or 1.25 mg to 20 mgRamipril or 12.5 mg to 450 mg Captopril or 0.5 mg to 8 mg Trandolaprilor 5 mg to 40 mg Benazepril or 5 mg to 80 mg Fosinopril or 0.5 mg to 80mg Lisinopril or 5 mg to 60 mg Moexipril or 1.25 mg to 40 mg Enalapril;or Angiotensin II Receptor Blockers (ARBs) such as 2 mg to 32 mgCandesartan or 75 mg to 300 mg Irbesartan or 10 mg to 40 mg Olmesartanor 12.5 mg to Losartan or 40 mg to 320 mg Valsartan or 10 mg to 80 mgTelmisartan or 200 mg to 800 mg Eprosartan; or Calcium Channel Blockers(CCBs) such as 15 mg to 60 mg Nifedipine or 15 mg to 60 mg Diltiazem or1.25 mg to 10 mg Amlodipine or 1.25 mg to 60 mg of other CCBs (e.g.Verampil, Nicardipine, Isradipine, Felodipine or Nisoldipine); CentralAgonists such as 125 mg to 2000 mg Methyldopa or 0.05 mg to 2.4 mgClonidine or 0.5 mg to 3 mg Guanfacine or 2 mg to 32 mg Guanbenz; orPeripheral-acting Adrenergic blockers such as 5 mg to 75 mg Guanadrel or5 mg to 50 mg Guanethidine or 0.05 mg to 1 mg Reserpine; or DirectVasodilators such as 5 mg to 300 mg Hydralazine or 2.5 mg to 100 mgMinoxidil; or Direct Renin Inhibitors such as 75 mg to 300 mg Tekturanaformulated in the IR form.

Example 30—Anti-Inflammatory/Anti-Hypertensive Drugs: Two DrugCombinations (IR/ER)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Diureticssuch as 200 mg to 400 mg Spiranolactone or 50 mg to 100 mg Triamptereneor 50 mg to 100 mg Hydrochlorothiazide (HCTZ) or 50 mg to 100 mgChlorthalidone or 100 mg to 600 mg Furosemide or 2.5 mg to 5 mgAmiloride Hydrochloride or 1 mg to 2.5 mg Metolazone; or Beta blockerssuch as 10 mg to 60 mg Timolol or 2.5 mg to 10 mg Cartelol Hydrochlorideor 5 mg to 50 mg Corredilol or 100 mg to 640 mg Propranolol or 10 mg to40 mg Betaxolol or 50 mg to 80 mg Penbutolol Sulfate or 250 mg to 450 mgMetoprolol or 250 mg to 1200 mg Acebutolol or 100 mg to 200 mg Atenololor 10 mg to 20 mg Pindolol or 250 mg to 2400 mg Labetolol; Alphablockers such as 2.5 mg to 16 mg Doxazocin or 2.5 mg to 20 mg Terazocinor 2.5 mg to 20 mg Prazocin; Angiotensin-converting enzyme (ACE)inhibitors such as 5 mg to 80 mg Quinapril or 2.5 mg to 20 mg Ramiprilor 50 mg to 450 mg Captopril or 2.5 mg to 8 mg Trandolapril or 15 mg to40 mg Benazepril or 25 mg to 80 mg Fosinopril or 5 mg to 80 mgLisinopril or 15 mg to 60 mg Moexipril or 5 mg to 40 mg Enalapril; orAngiotensin II Receptor Blockers (ARBs) such as 10 mg to 32 mgCandesartan or 150 mg to 300 mg Irbesartan or 25 mg to 40 mg Olmesartanor 25 mg to Losartan or 100 mg to 320 mg Valsartan or 25 mg to 80 mgTelmisartan or 250 mg to 800 mg Eprosartan; or Calcium Channel Blockers(CCBs) such as 25 mg to 60 mg Nifedipine or 25 mg to 60 mg Diltiazem or5.0 mg to 10 mg Amlodipine or 5 mg to 60 mg of other CCBs (e.g.Verampil, Nicardipine, Isradipine, Felodipine or Nisoldipine); CentralAgonists such as 250 mg to 2000 mg Methyldopa or 0.1 mg to 2.4 mgClonidine or 1.0 mg to 3 mg Guanfacine or 5 mg to 32 mg Guanabenz; orPeripheral-acting Adrenergic blockers such as 10 mg to 75 mg Guanadrelor 10 mg to 50 mg Guanethidine or 0.05 mg to 1 mg Reserpine; or DirectVasodilators such as 25 mg to 300 mg Hydralazine or 5 mg to 100 mgMinoxidil; or Direct Renin Inhibitors such as 100 mg to 300 mg Tekturanaformulated in the ER form.

Example 31—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/Beta Blockers

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR formcombined with Beta blockers such as 10 mg to 60 mg Timolol or 2.5 mg to10 mg Cartelol Hydrochloride or 5 mg to 50 mg Corredilol or 100 mg to640 mg Propranolol or 10 mg to 40 mg Betaxolol or 50 mg to 80 mgPenbutolol Sulfate or 250 mg to 450 mg Metoprolol or 250 mg to 1200 mgAcebutolol or 100 mg to 200 mg Atenolol or 10 mg to 20 mg Pindolol or250 mg to 2400 mg Labetolol formulated in ER form.

Example 32—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/BetaBlockers/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Beta blockerssuch as 0.5 mg to 60 mg Timolol or 1.25 mg to 10 mg CartelolHydrochloride or 1.5 mg to 50 mg Corredilol or 20 mg to 640 mgPropranolol or 2.5 mg to 40 mg Betaxolol or 10 mg to 80 mg PenbutololSulfate or 50 mg to 450 mg Metoprolol or 100 mg to 1200 mg Acebutolol or25 mg to 200 mg Atenolol or 2.5 mg to 20 mg Pindolol or 50 mg to 2400 mgLabetolol formulated in the IR form and combined with Diuretics such as200 mg to 400 mg Spiranolactone or 50 mg to 100 mg Triampterene or 50 mgto 100 mg Hydrochlorothiazide (HCTZ) or 50 mg to 100 mg Chlorthalidoneor 100 mg to 600 mg Furosemide or 2.5 mg to 5 mg Amiloride Hydrochlorideor 1 mg to 2.5 mg Metolazone formulated in the ER form.

Example 33—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/ACE Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with ACE inhibitors such as 5 mg to 80 mg Quinapril or 2.5mg to 20 mg Ramipril or 50 mg to 450 mg Captopril or 2.5 mg to 8 mgTrandolapril or 15 mg to 40 mg Benazepril or 25 mg to 80 mg Fosinoprilor 5 mg to 80 mg Lisinopril or 15 mg to 60 mg Moexipril or 5 mg to 40 mgEnalapril formulated in the form of ER.

Example 34—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/ACEInhibitors/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in IR form with ACEinhibitors such as 0.5 mg to 80 mg Quinapril or 1.25 mg to 20 mgRamipril or 12.5 mg to 450 mg Captopril or 0.5 mg to 8 mg Trandolaprilor 5 mg to 40 mg Benazepril or 5 mg to 80 mg Fosinopril or 0.5 mg to 80mg Lisinopril or 5 mg to 60 mg Moexipril or 1.25 mg to 40 mg Enalaprilformulated in the IR form will be combined with Diuretics such as 12.5mg to 400 mg Spiranolactone or 25 mg to 100 mg Triampterene or 12.5 mgto 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mg Chlorthalidoneor 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg Amiloride Hydrochlorideor 0.25 mg to 2.5 mg Metolazone formulated in the form of ER.

Example 35—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/ARBs

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with ARBs such as 2 mg to 32 mg Candesartan or 75 mg to 300mg Irbesartan or 10 mg to 40 mg Olmesartan or 12.5 mg to Losartan or 40mg to 320 mg Valsartan or 10 mg to 80 mg Telmisartan or 200 mg to 800 mgEprosartan formulated in the ER form.

Example 36—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/ARBs/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with (ARBs)such as 2 mg to 32 mg Candesartan or 75 mg to 300 mg Irbesartan or 10 mgto 40 mg Olmesartan or 12.5 mg to Losartan or 40 mg to 320 mg Valsartanor 10 mg to 80 mg Telmisartan or 200 mg to 800 mg Eprosartan formulatedin the IR form will be combined with Diuretics such as 12.5 mg to 400 mgSpiranolactone or 25 mg to 100 mg Triampterene or 12.5 mg to 100 mgHydrochlorothiazide (HCTZ) or 7.5 mg to 100 mg Chlorthalidone or 10 mgto 600 mg Furosemide or 0.5 mg to 5 mg Amiloride Hydrochloride or 0.25mg to 2.5 mg Metolazone formulated in the form of ER.

Example 37—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/CCBs

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with (CCBs) such as 25 mg to 60 mg Nifedipine or 25 mg to 60mg Diltiazem or 5.0 mg to 10 mg Amlodipine or 5 mg to 60 mg of otherCCBs (e.g. Verampil, Nicardipine, Isradipine, Felodipine or Nisoldipine)formulated in the ER form.

Example 38—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/CCBs/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with CCBs suchas 15 mg to 60 mg Nifedipine or 15 mg to 60 mg Diltiazem or 1.25 mg to10 mg Amlodipine or 1.25 mg to 60 mg of other CCBs (e.g. Verampil,Nicardipine, Isradipine, Felodipine or Nisoldipine) will be combinedwith Diuretics such as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100mg Triampterene or 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5mg to 100 mg Chlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5mg Amiloride Hydrochloride or 0.25 mg to 2.5 mg Metolazone formulated inthe form of ER.

Example 39—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/Central Agonists

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with Central Agonists such as 250 mg to 2000 mg Methyldopaor 0.1 mg to 2.4 mg Clonidine or 1.0 mg to 3 mg Guanfacine or 5 mg to 32mg Guanabenz formulated in the ER form.

Example 40—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/CentralAgonists/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with CentralAgonists such as 125 mg to 2000 mg Methyldopa or 0.05 mg to 2.4 mgClonidine or 0.5 mg to 3 mg Guanfacine or 2 mg to 32 mg Guanabenzformulated in the IR form will be combined with Diuretics such as 12.5mg to 400 mg Spiranolactone or 25 mg to 100 mg Triampterene or 12.5 mgto 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mg Chlorthalidoneor 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg Amiloride Hydrochlorideor 0.25 mg to 2.5 mg Metolazone formulated in the form of ER.

Example 41—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Peripheral-Acting Adrenergic Blockers/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form withPeripheral-acting Adrenergic blockers such as 10 mg to 75 mg Guanadrelor 10 mg to 50 mg Guanethidine or 0.05 mg to 1 mg Reserpine formulatedin the IR form will be combined with Diuretics such as 200 mg to 400 mgSpiranolactone or 50 mg to 100 mg Triampterene or 50 mg to 100 mgHydrochlorothiazide (HCTZ) or 50 mg to 100 mg Chlorthalidone or 100 mgto 600 mg Furosemide or 2.5 mg to 5 mg Amiloride Hydrochloride or 1 mgto 2.5 mg Metolazone formulated in the form of ER.

Example 42—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/Peripheral-Acting Adrenergic Blockers

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with Peripheral-acting Adrenergic blockers such as 10 mg to75 mg Guanadrel or 10 mg to 50 mg Guanethidine or 0.05 mg to 1 mgReserpine formulated in the ER form.

Example 43—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/Direct Vasodilators

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with Direct Vasodilators such as 25 mg to 300 mg Hydralazineor 5 mg to 100 mg Minoxidil formulated in the ER form or directvasodilators such as 25 mg to 300 mg Hydralazine or 5 mg to 100 mgMinoxidil formulated in the ER form.

Example 32—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/DirectVasodilators/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with DirectVasodilators such as 5 mg to 300 mg Hydralazine or 2.5 mg to 100 mgMinoxidil formulated in the IR form will be combined with Diuretics suchas 200 mg to 400 mg Spiranolactone or 50 mg to 100 mg Triampterene or 50mg to 100 mg Hydrochlorothiazide (HCTZ) or 50 mg to 100 mgChlorthalidone or 100 mg to 600 mg Furosemide or 2.5 mg to 5 mgAmiloride Hydrochloride or 1 mg to 2.5 mg Metolazone formulated in theform of ER.

Example 44—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Diuretics/Direct Renin Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in IR form willbe combined with Direct Renin Inhibitors such as 100 mg to 300 mgTekturana formulated in the ER form.

Example 45—Three Drug Combinations (IR/IR/ER): Anti-Inflammatory/DirectRenin Inhibitors/Diuretics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with DirectRenin Inhibitors such as 75 mg to 300 mg Tekturana formulated in the IRform will be combined with Diuretics such as 200 mg to 400 mgSpiranolactone or 50 mg to 100 mg Triampterene or 50 mg to 100 mgHydrochlorothiazide (HCTZ) or 50 mg to 100 mg Chlorthalidone or 100 mgto 600 mg Furosemide or 2.5 mg to 5 mg Amiloride Hydrochloride or 1 mgto 2.5 mg Metolazone formulated in the form of ER.

Example 46—Four Drug Combinations (IR/IR/ER/DR):Anti-Inflammatory/Diuretic/CCB/ACE Inhibitor

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with Diureticssuch as 12.5 mg to 400 mg Spiranolactone or 25 mg to 100 mg Triamptereneor 12.5 mg to 100 mg Hydrochlorothiazide (HCTZ) or 7.5 mg to 100 mgChlorthalidone or 10 mg to 600 mg Furosemide or 0.5 mg to 5 mg AmilorideHydrochloride or 0.25 mg to 2.5 mg Metolazone formulated in the IR formwith Calcium Channel Blockers (CCBs) such as 25 mg to 60 mg Nifedipineor 25 mg to 60 mg Diltiazem or 5.0 mg to 10 mg Amlodipine or 5 mg to 60mg of other CCBs (e.g. Verampil, Nicardipine, Isradipine, Felodipine orNisoldipine) formulated in the ER form will be combined with ACEinhibitors such as 0.5 mg to 80 mg Quinapril or 1.25 mg to 20 mgRamipril or 12.5 mg to 450 mg Captopril or 0.5 mg to 8 mg Trandolaprilor 5 mg to 40 mg Benazepril or 5 mg to 80 mg Fosinopril or 0.5 mg to 80mg Lisinopril or 5 mg to 60 mg Moexipril or 1.25 mg to 40 mg Enalaprilformulated in the DR form.

Example 47—Anti-Obesity: Two Drug Combinations (IR/IR)

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 50 mg to120 mg Xenical or 10 mg to 37.5 mg Phentermine or 5 mg to 10 mgLorcaserin or 10 mg to 37.5 mg Phentermine formulated in the form of IR.

Example 48—Two Drug Combinations (IR/ER): Anti-Obesity/Anti-Inflammatory

50 mg to 120 mg Xenical or 10 mg to 37.5 mg Phentermine or 5 mg to 10 mgLorcaserin or 10 mg to 37.5 mg Phentermine formulated in the form of IRwill be combined with 250 mg 500 mg Ibuprofen or 300 mg to 500 mgAspirin-like drugs or 200 mg to 400 mg Celecoxib or 200 mg to 500 mg ofSulindac or other known anti-inflammatory drugs will be formulated inthe form of ER.

Example 49—Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Anti-Obesity/DPPIV Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 50 mg to120 mg Xenical or 10 mg to 37.5 mg Phentermine or 5 mg to 10 mgLorcaserin or 10 mg to 37.5 mg Phentermine formulated in the form of IRwill be combined with DPP-IV inhibitors such as 250 mg Sitagliptin, 25mg Alogliptin or 10 mg Linagliptin formulated in the ER form.

Example 50—Three Drug Combinations (IR/IR/S.C. Injection):Anti-Inflammatory/Anti-Obesity/Incretin Mimetics

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 50 mg to120 mg Xenical or 10 mg to 37.5 mg Phentermine or 5 mg to 10 mgLorcaserin or 10 mg to 37.5 mg Phentermine formulated in the form of IRwill be combined with Subcutaneous (S.C.) injections of Incretinmimetics such as 5 ug Exenatide or 0.65 mg to 1.8 mg Liraglutide or 0.6mg to 1.8 mg Victoza.

Example 51—Prediabetes or Prevention of On-Set of Type II DiabetesDrugs: Two Drug Combinations (IR/IR): Anti-Inflammatory/ARBs or ACEInhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with (ACE)inhibitors such as 0.5 mg to 80 mg Quinapril or 1.25 mg to 20 mgRamipril or 12.5 mg to 450 mg Captopril or 0.5 mg to 8 mg Trandolaprilor 5 mg to 40 mg Benazepril or 5 mg to 80 mg Fosinopril or 0.5 mg to 80mg Lisinopril or 5 mg to 60 mg Moexipril or 1.25 mg to 40 mg Enalapril;or Angiotensin II Receptor Blockers (ARBs) such as 2 mg to 32 mgCandesartan or 75 mg to 300 mg Irbesartan or 10 mg to 40 mg Olmesartanor 12.5 mg to Losartan or 40 mg to 320 mg Valsartan or 10 mg to 80 mgTelmisartan or 200 mg to 800 mg Eprosartan formulated in the IR form.

Example 52—Prediabetes or Prevention of On-Set of Type II DiabetesDrugs: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/ARBs/Metformin

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with (ARBs)such as 2 mg to 32 mg Candesartan or 75 mg to 300 mg Irbesartan or 10 mgto 40 mg Olmesartan or 12.5 mg to Losartan or 40 mg to 320 mg Valsartanor 10 mg to 80 mg Telmisartan or 200 mg to 800 mg Eprosartan formulatedin the IR form will be combined with 500 mg to 2000 mg Metforminformulated in the ER form.

Example 53—Prediabetes or Prevent or Delay the On-Set of Type IIDiabetes Drugs: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/ACE Inhibitors/Metformin

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with ACEinhibitors such as 0.5 mg to 80 mg Quinapril or 1.25 mg to 20 mgRamipril or 12.5 mg to 450 mg Captopril or 0.5 mg to 8 mg Trandolaprilor 5 mg to 40 mg Benazepril or 5 mg to 80 mg Fosinopril or 0.5 mg to 80mg Lisinopril or 5 mg to 60 mg Moexipril or 1.25 mg to 40 mg Enalaprilformulated in the IR form will be combined with 500 mg to 2000 mgMetformin formulated in the ER form.

Example 54—Prediabetes or Prevention of On-Set of Type II DiabetesDrugs: Four Drug Combinations (IR/IR/ER/DR):Anti-Inflammatory/ARBs/Metformin/ACE Inhibitor

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with (ARBs)such as 2 mg to 32 mg Candesartan or 75 mg to 300 mg Irbesartan or 10 mgto 40 mg Olmesartan or 12.5 mg to Losartan or 40 mg to 320 mg Valsartanor 10 mg to 80 mg Telmisartan or 200 mg to 800 mg Eprosartan formulatedin the IR form with 500 mg to 2000 mg Metformin formulated in the ERform will be combined with ACE inhibitors such as 0.5 mg to 80 mgQuinapril or 1.25 mg to 20 mg Ramipril or 12.5 mg to 450 mg Captopril or0.5 mg to 8 mg Trandolapril or 5 mg to 40 mg Benazepril or 5 mg to 80 mgFosinopril or 0.5 mg to 80 mg Lisinopril or 5 mg to 60 mg Moexipril or1.25 mg to 40 mg Enalapril formulated in the DR form.

Example 55—FDC Formulations for Clinically Managing Insulin ResistanceSyndrome or Metabolic Syndrome: Two Drug Combinations (IR/IR/ER):Anti-Inflammatory/Metformin/Metformin

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 250 mg to500 mg Metformin formulated in the IR form will be combined with 250 mgto 2000 mg Metformin formulated in the ER form.

Example 56—FDC Formulations for Clinically Managing Insulin ResistanceSyndrome or Metabolic Syndrome: Two Drug Combinations (IR/IR/DR):Anti-Inflammatory/Metformin/Metformin

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 250 mg to500 mg Metformin formulated in the IR form will be combined with 250 mgto 2000 mg Metformin formulated in the DR form.

Example 57—FDC Formulations for Clinically Managing Insulin ResistanceSyndrome or Metabolic Syndrome: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Metformin/Atorvastatin

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 250 mg to500 mg Metformin formulated in the IR form will be combined with Statinssuch as 80 mg Atorvastatin or 80 mg Provastatin or 40 mg Rosuvastatin or40 mg Simvastatin formulated in the ER form.

Example 58—FDC Formulations for Clinically Managing Insulin ResistanceSyndrome or Metabolic Syndrome: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Metformin/ACE Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 250 mg to500 mg Metformin formulated in the IR form will be combined with ACEinhibitors such as 5 mg to 80 mg Quinapril or 2.5 mg to 20 mg Ramiprilor 50 mg to 450 mg Captopril or 2.5 mg to 8 mg Trandolapril or 15 mg to40 mg Benazepril or 25 mg to 80 mg Fosinopril or 5 mg to 80 mgLisinopril or 15 mg to 60 mg Moexipril or 5 mg to 40 mg Enalaprilformulated in the form of ER.

Example 59—FDC Formulations for Clinically Managing Insulin ResistanceSyndrome or Metabolic Syndrome: Three Drug Combinations (IR/IR/ER):Anti-Inflammatory/Metformin/ARBs

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with 250 mg to500 mg Metformin formulated in the IR form will be combined with (ARBs)such as 10 mg to 32 mg Candesartan or 150 mg to 300 mg Irbesartan or 25mg to 40 mg Olmesartan or 25 mg to Losartan or 100 mg to 320 mgValsartan or 25 mg to 80 mg Telmisartan or 250 mg to 800 mg Eprosartanformulated in the form of ER.

Example 60—FDC Formulations for Clinically Managing Insulin ResistanceSyndrome or Metabolic Syndrome: Four Drug Combinations (IR/IR/ER/DR):Anti-Inflammatory/DPP-IV Inhibitors/ARBs/ACE Inhibitors

200 mg Ibuprofen or 250 mg Naproxen-Sodium or 325 mg of Aspirin orAspirin-like drugs (e.g. Ascriptin, Ecotrin) or 50 mg to 400 mgCelecoxib or 200 mg Sulindac or an appropriate dose of other knownanti-inflammatory drugs will be formulated in the IR form with anti-typeII diabetic DPP-IV inhibitors such as 12.5 mg to 100 mg Sitagliptin, 3mg to 25 mg Alogliptin or 2.5 mg Linagliptin in an IR form withanti-hypertensive ARBs such as 2 mg to 32 mg Candesartan or 75 mg to 300mg Irbesartan or 10 mg to 40 mg Olmesartan or 12.5 mg to Losartan or 40mg to 320 mg Valsartan or 10 mg to 80 mg Telmisartan or 200 mg to 800 mgEprosartan formulated in the ER form will be combined with lipidlowering Statins such as 80 mg Atorvastatin or 80 mg Provastatin or 40mg Rosuvastatin or 40 mg Simvastatin formulated in the form of DR.

Examples 61-65: Additional FDC Formulations for Clinically Managing TypeII Diabetes and Prediabetes Example 61

In Example 61, 50 mg to 400 mg Celecoxib in an IR form will be combinedwith 500 mg to 1000 mg Metformin in an IR or ER or DR form administeredonce or twice daily.

Example 62

In Example 62, 50 mg to 400 mg Celecoxib in an IR form will be combinedwith 500 mg to 1000 mg Metformin in an IR or ER or DR form and 80 mg to160 mg Valsartan in a DR form administered once or twice daily.

Example 63

In Example 63, 50 mg to 400 mg Celecoxib in an IR form will be combinedwith 500 mg to 1000 mg Metformin in an IR or ER or DR form, 80 mg to 160mg Valsartan in a DR form and 80 mg of Atorvastatin in an ER formadministered once or twice daily.

Example 64

In Example 64, 50 mg to 400 mg Celecoxib in an IR form will be combinedwith 5 mg Linagliptin in IR form, 80 to 160 mg Valsartan in a DR formand 80 mg Atorvastatin in an ER form administered once or twice daily.

Example 65—Preparation of FDC Formulation of IR (Celecoxib) and ER(Metformin)

Example 65 is directed to the preparation of multilayer tablets of 50 mgto 400 mg Celecoxib in an IR form and 250 mg to 2000 mg of Metformin HClin an ER form. The IR drug containing layer will contain, e.g.,Celecoxib (50 mg to 400 mg), microcrystalline cellulose (50.0 mg),lactose monohydrate (78.0 mg), hydroxyl propyl cellulose (30.0 mg),Croscarmellose sodium (10.0 mg) and magnesium stearate (2.0 mg). The ERdrug containing layer will contain Metformin HCl (250 mg to 2000 mg),carnuba wax (290.0 mg), stearic acid (190.0 mg), silicon dioxide (10.0mg), and magnesium stearate (2.0 mg). The inert layer will containcarnauba wax (100.0 mg), dibasic calcium phosphate (58.0 mg), stearicacid (40 mg), and magnesium stearate (2.0 mg). The subcoating willcontain hydroxypropyl methyl cellulose (45.0 mg/tablet), polyethylglycol 400 (12.0 mg/tablet) and purified water which will be removedduring processing. The ER coating will contain Surelease (98.0mg/tablet), hydroxyl methyl cellulose (98.0 mg/tablet) and purifiedwater which will be removed during processing.

The IR drug containing the layer of the core tablet will be prepared asfollows: Celecoxib will be blended with all the ingredients exceptCroscarmellose sodium and magnesium stearate and granulated withpurified with water. The granulate will be dried and milled through asuitable screen. Croscarmellose sodium AND magnesium stearate will beadded to the milled granules. The mixture will then be blended for 2minutes.

The ER drug containing layer of the tablet will be prepared as follows:Metformin HCl and Carnauba wax will be mixed and granulated with asolution of stearic acid in ethyl alcohol.

The granulate will then be dried, milled through a suitable screen.Silicon dioxide and magnesium stearate will be screened and then addedto the milled granules. The mixture will then be blended for another 2minutes.

The inert layer will be prepared as follows: Carnauba wax and dicalciumphosphate will be mixed and granulated with a solution of stearic acidin ethyl alcohol. The granulate will then be dried, milled through asuitable screen. Magnesium stearate will be screened and then added tothe milled granules. The mixture will then be blended for another 2minutes.

The mixture will then be compressed into a multi-layer core tablet inthe following sequence: ER containing layer, inert layer and IR drugcontaining layer using a multi-layer tablet press. Core tablets willthen be subcoated.

The subcoating will be prepared by dissolving hydroxypropyl methylcellulose and polyethylene glycol 400 in purified water and sprayed as acoating solution onto the multi-layer core tablet in a coating pan.

The ER coating will be prepared as follows: In a container purifiedwater will be mixed with hydroxyl propyl methyl cellulose using a mixeruntil hydroxyl methyl cellulose was completely dissolved. Thehydroxymethyl cellulose solution was then added to the sureleasedispersion and mixed for 15 minutes. The resulting dispersion will bemixed during the entire coating process. Using the coating pan, thesurelease/hydroxypropyl methyl cellulose dispersion will be sprayed ontothe subcoated tablets until the required weight gain was achieved.

Example 66—Animal Studies

In Example 66, animal studies were conducted based on the methods andFDC formulations described herein. The studies were conducted using goodscientific practices following the applicable SOPs of the TestingFacility. Age and weight-matched C57BL/6J lean and DIO male mice wereobtained from Jackson Labs (Bar Harbor, Me.). C57BL/6J DIO mice were fedhigh-fat diet (HFD) for 16 weeks to induce hepatic insulin resistanceand pancreatic beta cell dysfunction. USP grade APIs suitable for thefinished products were obtained from LGM Pharma (Nashville, Tenn.). Leancontrol mice were maintained on D12450B (10% Kcal fat) Chow diet and DIOanimals were maintained D12492 (60% KCal fat) research diets. Tap waterwas available ad libitum during the study. Animals were acclimated for aweek. Animals were observed by lab technicians during the study andclinical examinations were performed by the veterinarians. Studydirector and the sponsor were notified in the event of abnormal behavioror observations. Test articles or the drugs were reconstituted in DMSOand 0.5% Methyl cellulose was used as the vehicle.

In a 5-day pilot study, Metformin (300 mg/Kg/day) and sub-maximal doseof Celecoxib (20 mg/Kg/day) were administered together or the vehiclewas administered as an oral gavage in the morning. Sub-hypertensive doseof Valsartan (2 mg/Kg/day) or the vehicle was administered 6 hourslater. Non-fasting blood glucose levels were determined prior to thedrug administration and then every hour for 8 hours using a handheldOneTouch, Ultra Blood Glucose Monitoring System (Johnson & Johnson). Inthe 5-day study, blood glucose (BG) levels were determined once in themorning prior to the drug administration and again in the afternoon.

Co-administration of Metformin (Metf), Celecoxib (Celec) and Valsartan(Val) improved non-fasting BG levels in C57BL/6J DIO mice within onehour post administration and the reduced level was maintained for atleast 8 hours on the first day of the treatment (N=6) (FIG. 9).Improvement in non-fasting or fed blood glucose levels within one hourpost administration is indicative of improvement in pancreatic beta celldysfunction. Two-way ANOVA, DIO vehicle vs. DIO Metf+Celc+Val, p<0.0001(****) significant.

Co-administration of Metformin, Celecoxib and Valsartan improvednon-fasting BG levels in C57BL/6J DIO mice for at least five days withonce-a-day oral administration (N=6) (FIG. 10). Two-way ANOVA, DIOvehicle vs. DIO Metf+Celc+Val, p<0.001 (***) significant.

In a 29-day study, sub-maximal dose of Metformin (150 mg/Kg/day) andsub-maximal doses of Celecoxib (10 mg/Kg/day or 20 mg/Kg/day) wereadministered together or the vehicle was administered as an oral gavagein the morning and a sub-hypertensive dose of Valsartan (2 mg/Kg/day) orthe vehicle was administered 6 hours later. Non-fasting BG measurementswill be taken on Days 1, 15, 22, and 29. Animals were transferred toclean cages, food and water were uninterrupted. A blood sample wascollected via tail nick and blood glucose was assessed using a hand-heldGlucometer. Body weights were determined twice weekly for the durationof the study period. Animals were observed by lab technicians during thestudy and clinical examinations were performed by the veterinarians.Body weights did not change significantly with different treatmentsduring the course of the 29-day study.

Co-administration of Metformin, Celecoxib and Valsartan counteracted theelevation of non-fasting BG in DIO animals treated with vehicle and DIOanimals treated with Metformin (N=6) during the 29-day study (FIG. 11).Co-administration of Metformin, Celecoxib and Valsartan was determinedsafe during the 29-day study by using body weight as a measure and fromobservations and clinical examinations by veterinarians.

Oral Glucose Tolerance Test (OGTT) was performed on all the animals onDay 29. Animals were fasted for 5 hours. All animals were kept in cleancages without access to food for 5 hours after BG reading and prior toOGTT. Water was available throughout the course of the OGTT assessment.Test articles were administered by oral gavage 30 minutes prior to theglucose challenge. Each animal was challenged with a glucose load of 2g/Kg body weight in water. Blood glucose from a tail nick was assessedusing a handheld glucometer at 0, 15, 30, 60, 90 and 120 minute timepoints.

Co-administration of Metformin, Celecoxib and Valsartan improved glucosetolerance in the oral glucose tolerance test (OGTT) (FIG. 12). Changesin blood glucose levels after glucose loading are shown. ***p<0.0001 vs.DIO vehicle and DIO Metformin. Changes in the total area under the curve(AUC 0-2 h) is shown in FIG. 13. ***p<0.0001 vs. DIO vehicle and DIOMetformin.

Blood glucose levels were assessed after 5-hour fast prior to theglucose challenge during the OGTT performed on the 29th day of thestudy, and demonstrated that co-administration of Metformin (150 mg/Kg),Celecoxib (10 or 20 mg/Kg) and Valsartan (2 mg/Kg) administrationimproved fasting blood glucose levels. (FIG. 14).

As shown in FIGS. 9 and 12, oral administration of a combination ofMetformin, Celecoxib (a selective Cox-2 inhibitor) and Valsartan (anARB) improves non-fasting blood glucose levels in less than 1 hourpost-administration and fasting blood glucose levels in less than 15minutes in the OGTT by improving the first phase insulin secretion(shown with arrows). Impairment of first phase of insulin secretion isdiagnostic of prediabetes as well as overt Type II diabetes.

The results of the animal studies disclosed herein demonstrate thatpro-inflammatory signals in general and Cox-2-mediated pancreatic celldysfunction in particular play a critically important role in thedevelopment of insulin resistance as well as loss of insulin-sensitiveregulation of hepatic gluconeogenesis. Maintenance of normal glucoselevels and hepatic gluconeogenesis are tightly controlled by opposingactions of insulin and glucagon. As shown in FIG. 15, treatment withMetformin alone did not suppress elevated non-fasting BG levels but itactually enhanced the BG levels due to lack of insulin-sensitivefeed-back regulation of glucagon-mediated hepatic gluconeogenesis. It ishypothesized that in the absence of post-prandial elevation ofsufficient insulin due to beta cell dysfunction, Metformin stabilizedglucagon-permissive CREB-CBP-TORC2 transcription complex to activatehepatic gluconeogenesis resulting in elevated BG levels. Co-treatmentwith Celecoxib, a selective Cox-2 inhibitor and a sub-hypertensive yetanti-inflammatory dose of Valsartan counteracted Metformin-mediatedelevation in non-fasting BG levels by correcting beta cell dysfunctionas well as by restoring insulin sufficiency and insulin sensitivity forregulation of hepatic gluconeogenesis. As illustrated schematically, itis hypothesized that this occurs by insulin-mediated triggering ofdisassembly of the glucagon-permissive CREB-CBP-TORC2 transcriptioncomplex by phosphorylation of co-activator CBP at Ser246, and nuclearexclusion and degradation of co-activator TORC2 by phosphorylation atSer171 (FIG. 15).

As shown in FIGS. 11, 12 and 14, treatment with Metformin alone did notsuppress elevated non-fasting BG levels in C57BL/6J DIO (diet-inducedobesity) mice but it slightly enhanced the BG levels due to lack ofinsulin-sensitive feed-back regulation of glucagon-mediated hepaticgluconeogenesis. It is hypothesized that in the absence of post-prandialelevation of sufficient insulin due to beta cell dysfunction, Metforminstabilized glucagon-permissive CREB-CBP-TORC2 transcription complex toactivate hepatic gluconeogenesis resulting in elevated BG levels.Co-treatment with sub-optimal dose Celecoxib (10 mg/Kg and 20 mg/Kg), aselective Cox-2 inhibitor and a sub-hypertensive yet anti-inflammatorydose of Valsartan (2 mg/Kg) counteracted Metformin-mediated elevation ofnon-fasting as well as fasting BG levels by correcting beta celldysfunction as well as by restoring insulin sufficiency and insulinsensitivity for regulation of hepatic gluconeogenesis. As illustratedschematically, it is hypothesized that this occurs by insulin-mediatedtriggering of disassembly of the glucagon-permissive CREB-CBP-TORC2transcription complex by phosphorylation of co-activator CBP at Ser246,and nuclear exclusion and degradation of co-activator TORC2 byphosphorylation at Ser171 (FIG. 15).

CONCLUSION

The above-described results provide proof-of-concept of theanti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) blood glucose levels by oral administration ofsub-therapeutic dose of Celecoxib (a selective Cox-2 inhibitor) incombination with therapeutic dose of anti-hyperglycemic drug, Metforminand sub-systolic blood pressure dose of an ARB, Valsartan reduces Bloodglucose levels more efficiently in C57BL/6J (B6) DIO (Diet-inducedObesity) mice.

The above-described results provide proof-of-concept that theanti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) Blood glucose levels by oral administration ofsub-therapeutic dose of Celecoxib (a selective Cox-2 inhibitor) incombination with therapeutic dose of Metformin and sub-hypertensive doseof Valsartan reduces non-fasting blood glucose levels within one hourpost administration on day 1 to near or slightly below the C57BL/6J DIOmice treated with the vehicle. Rapid lowering of non-fasting or fedblood glucose levels is indicative of improvement in pancreatic betacell dysfunction.

The above-described results provide proof-of-concept of theanti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) blood glucose levels by oral administration ofsub-therapeutic dose of Celecoxib (a selective Cox-2 inhibitor) incombination with therapeutic dose of Metformin and sub-systolic bloodpressure dose of Valsartan reduces non-fasting blood glucose levelswithin one hour post administration to near or slightly below theC57BL/6J DIO mice treated with the vehicle and is sustained for at least8 hours on day 1 of administration.

The above-described results further provide proof-of-concept of theanti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) blood glucose levels by daily (once-a-day) oraladministration of sub-therapeutic dose of Celecoxib (a selective Cox-2inhibitor) in combination with therapeutic dose of Metformin andsub-systolic blood pressure dose of Valsartan reduces non-fasting Bloodglucose levels to near or slightly below the C57BL/6J DIO mice treatedwith the vehicle for at least 5 days.

The above-described results further provide proof-of-concept of theanti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) blood glucose levels by daily (once-a-day) oraladministration of sub-therapeutic dose of Celecoxib (a selective Cox-2inhibitor) in combination with therapeutic dose of Metformin combined assingle dose simulating to an Immediate Release (IR) or Quick Release(QR) and administration of sub-systolic blood pressure dose of Valsartan6 hours later simulating Delayed Release (DR) reduces non-fasting bloodglucose levels to near or slightly below the C57BL/6J DIO mice treatedwith the vehicle for at least 5 days.

The above-described results provide proof-of-concept of theanti-inflammatory pancreatic beta cell-centric approach for managingnon-fasting (fed) blood glucose levels by daily (once-a-day) oraladministration of sub-therapeutic dose of Celecoxib (a selective Cox-2inhibitor) in combination with sub-maximal/therapeutic dose of Metforminand sub-systolic blood pressure dose of Valsartan is safe as determinedby using body weight (BW) as a measure as well as examination byveterinarians in C57BL/6JJ DIO mice for a long term use of at least 29days.

Finally, the above-described results suggest that the POC data disclosedhere suggest that the anti-inflammatory pancreatic beta cell-centricproduct combination has the potential for long term sustainable glycemiccontrol by maintaining optimal glucagon-insulin molar ratio bycorrecting pancreatic beta cell dysfunction and by restoring hepaticinsulin sensitivity. For efficient management of insulin resistance,chronic hyperglycemia due to systemic glucose intolerance should not betreated in isolation without treating the causative low-gradeinflammation. Progressive deterioration of metabolic control of glucosehomeostasis in spite of intense treatments with anti-hyperglycemic drugsis indicative of progressive deterioration of pancreatic islet celldysfunction resulting in insulin insufficiency. Blood glucose levels andhepatic gluconeogenesis are tightly regulated by opposing actions ofinsulin and glucagon. Ant-Inflammatory beta-cell centric methods andformulations disclosed are designed to treat pancreatic beta celldysfunction in combination with insulin resistance by restoring insulinsufficiency as well as restoring insulin sensitivity for hepaticgluconeogenesis as a result of optimal insulin-glucagon molar ratio.

The POC data disclosed here suggest that the anti-inflammatorypancreatic beta cell-centric product combination has the potential totreat impaired post-prandial as well as fasting blood glucose levels.The POC data disclosed here suggest that the anti-inflammatorypancreatic beta cell-centric product combination has the potential todelay, prevent or reduce the severity of obesity-triggered insulinresistance and hyperglycemia in prediabetes, phase I and phase II type 2diabetes patients. The POC data disclosed here suggest that theanti-inflammatory pancreatic beta cell-centric product combination hasthe potential for long term sustainable glycemic control would result inbetter patient CV (cardiovascular) outcomes in long-term clinicalstudies.

Based on the preclinical data reported herein and information providedherein, for efficient management of insulin resistance, chronichyperglycemia due to systemic glucose intolerance should not be treatedin isolation without treating the causative low-grade inflammation.

Data disclosed herein suggest that treatment with a combination of ananti-hyperglycemic drug such as Metformin, a selective Cox-2 inhibitorsuch as Celecoxib and anti-hypertensive drug such as Valsartan withtheir inherent anti-inflammatory capacity has the potential forsustainable glycemic control by correcting pancreatic beta celldysfunction and by restoring hepatic insulin sensitivity in type 2diabetes patients with obesity-triggered insulin resistance. Asillustrated schematically in FIG. 15, it is hypothesized thatsustainable glycemic control is achieved by restoring insulinsensitivity for inhibition of hepatic gluconeogenesis by means ofinsulin-dependent disruption of glucagon-permissive transcriptioncomplex resulting in inhibition of gluconeogenic genes such as PEPCK andPGC-1 alpha.

Pertaining to this disclosure, anti-inflammatory pancreatic betacell-centric platform combines drugs at the appropriate doses of ananti-inflammatory drug (e.g. a selective Cox-2 inhibitor) with metabolicand cardiovascular disease drugs along with predetermined releasekinetics to achieve optimal therapeutic as well as kinetic synergies. Incertain preferred embodiments, the anti-inflammatory pancreatic betacell-centric drug formulations of the invention will becustom-formulated to treat patient-specific comorbidities and moreimportantly, achieve long term sustainable glycemic control bycorrecting pancreatic islet dysfunction. The methods and formulationsdescribed herein may represent a new first line of therapy and a newstandard of care for treating Prediabetes, Phase I and Phase II diabetespatients. It is believed that lowering inflammatory parameters incombination with managing hypertension and lowering lipid profiles wouldresult in more rapid improvement in outcomes with optimal glycemiccontrol. An innovative pharmaceutical formulations and methods platformcalled “ParamAushadam™” (means Perfect Medicine in Sanskrit, pending,Serial Number: 86/86456) Description: A pharmaceutical finished productmethods and formulations technology that combines therapeuticallyefficacious adverse side effect and DDI-sparing doses of drugs withpredetermined modified drug release kinetics to achieve optimaltherapeutic as well as kinetic synergies.

Various modifications and variations of the described method and systemof the invention will be apparent to those skilled in the art withoutdeparting from the scope and spirit of the invention. Although theinvention has been described in connection with specific desiredembodiments, it should be understood that the invention as claimedshould not be unduly limited to such specific embodiments. Indeed,various modifications of the described modes for carrying out theinvention that are obvious to those skilled in the fields of medicine,immunology, pharmacology, endocrinology, pharmaceutics or related fieldsare intended to be within the scope of the invention as defined by thefollowing claims.

BIBLIOGRAPHY

-   1. Garber, A. J. et al. (2013) American association of clinical    endocrinologists' comprehensive diabetes management algorithm 2013    consensus statement. Endocrine Practice 10 (Suppl.) 19:1-48.-   2. Sullivan, P. W. et al. (2007) The medical cost of cardiometabolic    risk factors in the united states. Obesity 15 (12): 3150-3158.-   3. Statistics about diabetes (2014) Data from the National Diabetes    Statistics Report (released Jun. 10, 2014), American Diabetes    Association.-   4. www.cdc.gov Mortality data 2010.-   5. www.drugstorenews.com Sep. 24, 2013. From GBI Research, Global    Business Intelligence-   6. www.biovision.com-   7. Erik, P. et al (2009) Pathogenesis and Pathophysiology of    cardiometabolic syndrome. J. Clin. Hypertension 11 (12): 761-765.-   8. Leung, P. S. (2007) Mechanisms of protective effects induced by    blockade of the renin-angiotensin system: novel role of the    pancreatic islet Angiotensin-generating system in type 2 diabetes.    Diabet. Med. 24 (2): 110-116.-   9. Aguilar, D. and Solomon, S D (2006) ACE inhibitors and    Angiotensin receptor antagonists and the incidence of new-onset    diabetes mellitus: an emerging theme. Drugs 66 (9):1169-1177.-   10. Choosing a Type 2 diabetes drug (2012) Annals of Internal    Medicine, American College of Physicians.-   11. Shende, P. et al. (2012) Multi-layered Tablet: Current Scenarios    and recent advances. Intl. J. Drug Del. 4: 418-426.-   12. Khan, Z. et al. (2013) A novel multi-layered multidisc oral    tablet for chronotherapeutic drug delivery. Biomed. Res. Intl.    Article ID: 569470, 16 pages.-   13. www.webmd.com-   14. www.drugs.com-   15. Standards of medical care in diabetes—2015 (2015) Diabetes Care    38 (Suppl. 1): S1-S94.-   16. Poitou, V. and R. P. Robertson (2009) Glucolipotoxicity: Fuel    excess and beta cell dysfunction. Endocrine Reviews 29(3): 351-366.-   17. Robertson, R. P. (1998) Dominance of Cyclooxygenase-2 in the    regulation of pancreatic islet prostaglandin synthesis. Diabetes 47:    1379-1383.-   18. Saltiel, A. (2000) The molecular and physiological basis of    insulin resistance: implications for metabolic and cardiovascular    diseases. J. Clin. Invest. 100 (2): 163-164.-   19. Sauter, N., C. Thienel, Y. Plutino, K. Kampe, E. Dror, S.    Traub, K. Tamper, B. Edat, F. Attou, J. Kerr-Conte, A. W. Jehle, M.    Boni-Schnitzler and M. Donath (2015) Angiotensin II induces    interleukin-1beta-mediated islet inflammation and beta cell    dysfunction independently of vasoconstrictive effects. Diabetes 64:    1273-1283.-   20. Shu, C. J., C. Benoist and D. Mathis (2012) The immune systems's    involvement in obesity-driven type 2 diabetes. Semi. Immunol. 24(6):    436-442.-   21. Tateya, S., F. Kim, and Y. Tamori (2013) Recent advances in    obesity-induced inflammation and insulin resistance. Frontiers in    Endocrine. 4: 1-14.-   22. Weir, G. C. and S. Bonner-Weir (2004) Five stages of evolving    beta cell dysfunction during progression to diabetes. Diabetes 53    (Suppl. 3): S16-S21.-   23. Weir, G. C., G. L King, A. M. Jacobson, A. C. Moses and C. R.    Kahn (2005) C. Ronald Kahn—Joslin's Diabetes Mellitus: 14th (fourth)    Edition Hardcover—Dec. 6, 2005

What is claimed is:
 1. A pharmaceutical formulation for the treatment ofmetabolic syndrome comprising (i) a therapeutically effective amount(s)of an active agent selected from the group consisting of at least oneanti-diabetic drug; or (ii) a therapeutically effective amount of atleast one anti-hypertensive drug; or (iii) a therapeutically effectiveamount of at least one anti-obesity drug; or (iv) a therapeuticallyeffective amount of at least one drug for the treatment ofhyperlipidemia; or (v) a combination of any of (i), (ii), (iii), and(iv); and (vi) a therapeutically effective amount of at least one orallyactive anti-inflammatory drug.
 2. The pharmaceutical formulation ofclaim 1, comprising a therapeutically effective amount(s) of a drugselected from the group consisting of at least one anti-diabetic drug,an anti-hypertensive drug, and a therapeutically effective amount of atleast one orally active anti-inflammatory drug.
 3. The pharmaceuticalformulation of claim 1, comprising therapeutically effective amounts ofat least two drugs selected from the group consisting of at least one ananti-hypertensive drug, at least one anti-diabetic drug, at least onedrug for the treatment of hyperlipidemia, at least one anti-obesitydrug, and at least one anti-inflammatory drug.
 4. The pharmaceuticalformulation of claim 1, comprising therapeutically effective amounts ofat least one an anti-hypertensive drug, at least one anti-diabetic drug,at least one drug for the treatment of hyperlipidemia, at least oneanti-obesity drug, and at least one anti-inflammatory drug.
 5. Thepharmaceutical formulation of claim 1, wherein the metabolic syndrome isType II diabetes, comprising therapeutically effective amounts of acombination of one or more anti-inflammatory drug(s) and at least onedrug used in the treatment of Type II Diabetes.
 6. The pharmaceuticalformulation of claim 1 wherein the metabolic syndrome is Type IIdiabetes, comprising a therapeutically effective amount(s) of a drugselected from the group consisting of at least one anti-diabetic drugand a blocker of Renin-Angiotensin System (RAS).
 7. The pharmaceuticalformulation of claim 1 for the treatment of hyperlipidemia, comprisingtherapeutically effective amounts of a combination of one or moreanti-inflammatory drug(s) and one or more drugs selected from the groupconsisting of a statin, niacin, a fibrate, and combinations of any ofthe foregoing.
 8. The pharmaceutical formulation of claim 1 for thetreatment of obesity comprising therapeutically effective amounts of acombination of one or more anti-inflammatory drug(s) and one or moredrugs selected from the group consisting of an anti-obesity drug, ananti-diabetic drug, and combinations of any of the foregoing.
 9. Thepharmaceutical formulation of claim 1 for the treatment of hypertension,comprising therapeutically effective amounts of one or more drugsselected from the group consisting of a beta blocker, a diuretic, an ACEinhibitor, an Angiotension II Receptor Blocker (ARBs), Calcium channelblocker (CCBs), a central agonist, a peripheral-acting adrenergicblocker, a direct vasodilator, a direct renin inhibitor, andcombinations of any of the foregoing; and at least one anti-inflammatorydrug.
 10. The pharmaceutical formulation of claim 1, which is an oralsolid dosage form.
 11. The pharmaceutical formulation of claim 1, whichis a dosage form selected from the group consisting of an oral dosageform, a parenteral dosage form, a transdermal dosage form, and a nasaldosage form.
 12. The formulation of claim 1, wherein at least one of thedrugs is in controlled or delayed release form.
 13. A method of treatingmetabolic syndrome, comprising administering to a human patient having acondition selected from the group consisting of Type II diabetes,Hypertension, Hyperlipidemia and Obesity, a pharmaceutical formulationfor the treatment of metabolic syndrome comprising (i) a therapeuticallyeffective amount(s) of a drug selected from the group consisting of atleast one anti-diabetic drug; or (ii) a therapeutically effective amountof at least one anti-hypertensive drug; or (iii) a therapeuticallyeffective amount of at least one anti-obesity drug; or (iv) atherapeutically effective amount of at least one drug for the treatmentof hyperlipidemia; or (v) a combination of any of (i), (ii), (iii), and(iv); and (vi) a therapeutically effective amount of at least one orallyactive anti-inflammatory drug.
 14. The method of claim 13, wherein thepatient is diabetic or prediabetic, comprising administering atherapeutically effective amount(s) of a drug selected from the groupconsisting of at least one anti-diabetic drug, a blocker ofRenin-Angiotensin System (RAS), and a combination of the foregoing,together with a therapeutically effective amount of at least one orallyactive anti-inflammatory drug.
 15. The method of claim 13, wherein oneor more of an ACE inhibitor, an angiotension II receptor blocker (ARBs),a DPPIV inhibitor, at least one anti-diabetic drug, a blocker ofRenin-Angiotensin System (RAS), together with a therapeuticallyeffective amount of at least one orally active anti-inflammatory drug,are administered to the patient.
 16. The method claim 13, wherein thedrugs are administered to the patient on a chronic basis.
 17. The methodof claim 14, wherein the drugs are administered as personalizedmedicines to clinically manage Type II diabetes or prediabetes instratified groups of human patients based on their cardiometabolic riskfactor profiles.
 18. The method of claim 14, wherein the drugs areadministered as personalized medicines to clinically manage Type IIdiabetes or prediabetes groups of patients stratified for lack ofadequate therapeutic efficacy with prior treatments.
 19. The method ofclaim 14, further comprising concomitantly administering insulin to thepatient to achieve better blood glucose control.
 20. The method of claim14, wherein dosage is adjusted on the basis of glucose measurements.